Wholesale Buyer’s Authorization Form

Licensee Legal Name as shown on License(Required)

DBA (name on signage)(Required)

Licensee Number(Required)

PST Number(Required)

Billing address(Required)

Street Address Address Line 2 City Province Postal Code

Business Phone(Required)

Shipping Address

Street Address Address Line 2 City Province Postal Code

If different from billing address.

Special Delivery Instructions

Payables Email Address(Required)

Payables Contact Name(Required)

First Last

Wholesale Orders email address

Wholesale Orders Contact (manager)(Required)

First Last

Website

If you wish 40 Knots to promote wines at your location.

Method of Payment(Required)

Visa

Mastercard

Amex

EFT (must have credit card as back up payment type)

Debit (in store pick up)

Cheque (must have credit card as back up payment type)

Name on Credit Card (legally responsible for account)

Credit Card number(Required)

Expiry Date(Required)

CVV – Card Verification Value(Required)

Date Signed(Required)

Agreed and Authorized by

First Last

Signature (type in authorized name again)(Required)

Title(Required)

Is there anything else you would like us to know?

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