Become a Retailer Partner Home Become a Retailer Become an NCD Retailer Save my progress and resume later | Resume a previously saved form Resume Later In order to be able to resume this form later, please enter your email and choose a password. Your Email: A Password: Confirm Password: Password must contain the following: 12 Characters 1 Uppercase letter 1 Lowercase letter 1 Number 1 Special character LEGAL BUSINESS INFORMATION BUSINESS NAME LEGAL BUSINESS NAME If different from above TAX ID # / FEDERAL EIN Type of OWNERSHIPPlease select... Corporation Partnership Individual LLC Non-Profit Other TYPE OF BUSINESSPlease select... DELI CONVENIENCE STORE MULTI-STORE OPERATOR TOBACCO SHOP CBD / VAPE SHOP EDUCATIONAL INSTITUTION HOSPITAL BODEGA OTHER YEARS IN BUSINESS BUSINESS ADDRESS StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau OFFICE TELEPHONE WEBSITE URL INCORPORATION SPECIFIC State of IncorporationPlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Date of Incorporation OWNER / OFFICER YOUR NAME (NAME OF PRINCIPAL) ADDRESS if different than above StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau YOUR EMAIL MOBILE PHONE Will you be the personal guarantor?Please select... YES, I AM THE PERSONAL GUARANTOR NO, I WILL ENTER A DIFFERENT CONTACT AS THE PERSONAL GUARANTOR BELOW NO, I WILL UPLOAD THE INFORMATION AT A LATER DATE For valuable consideration received, the undersigned personally guaranties payment and performance of all obligations, past, present and future of the above-named business, owing to NCD including any and all finance charges, cost of collection and reasonable attorney's fees in the amount not less that 33 1/3 percent. The undersigned waives presentment, demand, protest and any other notice regarding this Guaranty of Payment. The undersigned hereby submits his/her/itself to the personal jurisdiction of choosing of NCD and waives all rights to trial by jury. Real Estate Owned by Business LOCATION LIEN HOLDER NAME SOCIAL SECURITY # STATE ISSUED ID # STATE ISSUED ID EXPIRATION DATE UPLOAD A COPY OF YOUR STATE ISSUED ID MUST PROVIDE A VALID AND CLEAR COPY OF STATE ISSUED ID (IE. DRIVERS LICENSE) DOWNLOAD PERSONAL GUARANTOR FORM FOR SUBMISSION AT A LATER DATE. NOTE: CUSTOMER APPROVAL WILL BE DELAYED. OTHER GUARANTOR'S PERSONAL INFORMATION Real Estate Owned by Business LOCATION LIEN HOLDER NAME NAME OF PRINCIPAL ADDRESS StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau EMAIL MOBILE PHONE SOCIAL SECURITY # STATE ISSUED ID # STATE ISSUED ID EXPIRATION DATE UPLOAD A COPY OF THE GUARANTORS STATE ISSUED ID MUST PROVIDE A VALID AND CLEAR COPY OF STATE ISSUED ID (IE. DRIVERS LICENSE) For valuable consideration received, the undersigned personally guaranties payment and performance of all obligations, past, present and future of the above-named business, owing to NCD including any and all finance charges, cost of collection and reasonable attorney's fees in the amount not less that 33 1/3 percent. The undersigned waives presentment, demand, protest and any other notice regarding this Guaranty of Payment. The undersigned hereby submits his/her/itself to the personal jurisdiction of choosing of NCD and waives all rights to trial by jury. GURANTOR'S SIGNATURE THIS FIELD ENTRY IS AN EXECUTABLE SIGNATURE DATE GUARANTOR EXECUTED ABOVE LICENSES & STATE BUSINESS INFORMATION CIGARETTE LICENSE INFORMATION Type of LicensePlease select... Wholesale Tobacco License Retail Tobacco License We don't have a tobacco license UPLOAD A COPY OF YOUR TOBACCO LICENSE CIGARETTE/TOBACCO LICENSE # CIGARETTE/TOBACCO LICENSE EXPIRATION DATE BUSINESS LICENSE + TAX INFO UPLOAD A COPY OF YOUR RESALE CERTIFICATE See below for your state's documentation/templates UPLOAD A COPY OF YOUR SALES TAX LICENSE STATE RESALE TEMPLATESDownload, fill out, then upload completed if you do not have copies. UNIFORM SALES & USE TAX CERTIFICATE—MULTI-JURISDICTIONDownload the multi-state Jurisdiction Uniform Sales & Use Tax Certificate NEW YORK FORMSDownload NY HLA Resale Certificate PENNSYLVANIA FORMSDownload Pennsylvania Resale Certificate NEW JERSEY FORMSDownload New Jersey Resale Certificate MASSACHUSETTS FORMSDownload Massachusetts Resale Certificate VIRGINIA FORMSDownload Virginia Resale Certificate RHODE ISLAND FORMSDownload Rhode Island Resale Certificate REQUIRED BUSINESS FORMS regardless of State Upload a copy of your W-9 Download W-9 Form if you do not have one BANK REFERENCE BANK BRANCH CONTACT NAME CONTACT PHONE BANK ADDRESS LINE 1 BANK ADDRESS LINE 2 BANK CITY BANK STATEPlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau BANK ZIPCODE CONTACT EMAIL ADDRESS BANK ACCOUNT # TRADE REFERENCES - DO NOT USE C.O.D VENDORS PLEASE SUBMIT A MINIMUM OF 2 TRADE REFERENCES (CLICK 'ADD ANOTHER RESPONSE' UNDER SECTION) SUPPLIER NAME TYPES OF GOODS PURCHASED CONTACT NAME CONTACT PHONE ADDRESS LINE 1 ADDRESS LINE 2 CITY STATEPlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau ZIPCODE CONTACT EMAIL ADDRESS ACCOUNT # IF APPLICABLE EFT INFORMATION DEPOSITORY NAME BRANCH BANK ADDRESS LINE 1 BANK ADDRESS LINE 2 BANK CITY BANK STATEPlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau BANK ZIPCODE Account TypePlease select... Checking Savings DRAFT DAYPlease select... Monday Tuesday Wednesday Thursday Friday Saturday BANK ABA ROUTING # BANK ACCOUNT # BANKING EMAIL ADDRESS FOR CONFIRMATIONS AND OTHER BANKING COMMUNICATIONS VOIDED CHECK must upload a voided check image if 'checking account' is selected EFT DISCLAIMER I (WE) hereby authorize National Convenience Distributors, LLC (hereinafter called Company) to initiate debit entries to my (our) account selected above and indicated with the (hereinafter) called Depository, to debit the same to such account. This authority is to remain in full force and effect until Company has received written notification from either party of its termination and the opportunity to act on it.CHECK BOX TO VALIDATE Save my progress and resume later | Resume a previously saved form
