Application For Account

Business Contact Information

Name Of Your Atlantic Bottling Sales Rep

Account Number

If available

Company Name*

Atlantic Bottling Account Name*

Email*

Registered Company Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Is Delivery Address The Same As Above?*

Delivery Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Is this Account an additional location to an Existing Account?*

Existing Acct Name*

Existing Acct No.*

Business Type*

Tax ID*

Upload W-9*

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Are You Sales Tax Exempt?*

Upload Sales Tax Exemption Form*

No File Chosen

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Payment Terms (Select Preference)

Payment Terms*

TO RECEIVE EMAIL STATEMENTS, PLEASE PROVIDE EMAIL ADDRESS

Signature

The undersigned agrees to the terms set forth above. Additionally, the information given on this application is complete and correct to the best of my knowledge and I authorize verification of the above information.

Signature*

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Use your mouse or finger to draw your signature above

Print Name*

Title*

Today's Date*

Personal Guarantee (Required For Sole Proprietorship)

The undersigned guarantee the payment of all charges incurred by applicant and promise to pay same upon demand as individuals.

Signature*

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Use your mouse or finger to draw your signature above

Print Name*

Title*

Today's Date*

Direct Payment Via ACH Authorization

I authorize Atlantic Bottling Company, hereinafter called “Company” to initiate debit entries to my account indicated below and the Financial Institution named below, hereinafter called “Financial Institution,” to debit the same account. I acknowledge that the origination of ACH transactions to my account must comply with U.S. law.

Name On Checking Account*

Financial Institution Name*

Address*

City

State

ZIP Code

Routing Number*

Account Number*

Upload Image Of VOID Check*

No File Chosen

File uploads may not work on some mobile devices.

Atlantic Bottling Company Account Name and No. (please list all acct numbers)*

Payment Details*

ACH - Weekly. Amount from previous weeks’ invoices (Sun.-Sat.) withdrawn on Thursday the following week. ACH - Monthly. Amount from previous monthly statement withdrawn on the 10th of each month. ACH - Monthly. Amount from previous monthly statement withdrawn on the 20th of each month.

If the above date falls on a weekend or Holiday, the funds will be deducted the following business day.

This authorization is to remain in full force and effect until Company had received written notification from me (or any authorized account signer) of its termination in such time and manner as to afford the Company a reasonable opportunity to act on the request.

Print Individual Name*

Signature*

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Today's Date*

Account Contact Person*

Account Contact Email*

Account Contact Phone Number*

All Accounts are required to complete the Application for Business Account. ACH Terms require this form along with copy of check or bank letter to verify bank information.