New York Account Application

Legal Name

DBA

Federal Tax Identification #

Account Type RestaurantRetailer

New York SLA License Serial #

New York Resale Certificate #

New York Resale Certificate Expiration Date

Billing Address

Billing Address Line 2

Billing City

Billing State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Billing Zip

A/P Contact Name

A/P Telephone

A/P Email (for statements)

Delivery Address

Delivery Address Line 2

Delivery City

Delivery State New York

Delivery Zip

Delivery hours (4 hour minimum)

Delivery instructions (optional)

Wine Buyer Contact Name

Wine Buyer Telephone

Wine Buyer Email

Principal Name/Title

Martine's Wines Sales Rep (optional)

Upload a copy of your signed ST-120 resale certificate

Please note: an ST-120 resale certificate is different than a certificate of authority, seller’s permit, or liquor license – download a blank ST-120 resale certificate to fill out here www.tax.ny.gov/pdf/current_forms/st/st120_fill_in.pdf