Dana Distributors | Beverage Distribution in Goshen, NY

Beverage Application

Address

Dana Distributors, Inc.
52 Hatfield Lane
Goshen, New York 10924

Downloads

NY Tax Certification Form (ST-120) Please print and fill-out the required ST-120 form and then upload when completed.
PDF Scan/ JPG Photograph & Email to info@danadistributors.com

View FORM ST-120

Phone

(845) 294-4100

Fax

(845) 294-4111

Email

info@danadistributors.com

Office Hours

Monday through Friday
8:30 am - 5:00 pm

Application Type *

Alcoholic Beverage Application

Non-Alcoholic Beverage Application

Please fill the required field.

Company Name *Please fill the required field.

Parent Company/DBA *Please fill the required field.

Address *Please fill the required field.

Street Line 2

City *Please fill the required field.

State *Please fill the required field.

Zip Code *Please fill the required field.

Federal Tax ID# *Please fill the required field.

Phone *Please fill the required field.

Fax

Years In Business *Please fill the required field.

Liquor License # *Please fill the required field.

Name of Buyer *Please fill the required field.

Previous Business Name

Date of Submission *Please fill the required field.

Owner Information

Business Type *

Corporation

Partnership

Sole Proprietorship

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Contact Email *Please fill the required field.

Business Name *Please fill the required field.

Owner's Full Name *Please fill the required field.

Owner's Street Address *Please fill the required field.

Social Security #

Street Line 2

Owner's City *Please fill the required field.

Owner's State *Please fill the required field.

Owner's Zip Code *Please fill the required field.

Banking Information

Driver's License Number

Bank Name

Bank Phone

Type of Account

Account Number

Trade References

For Credit terms, please list three references only.

Company #1: Name / Phone

Company #2: Name / Phone

Company #3: Name / Phone

Agreement

I acknowledge that the terms offered by Dana Distributors, Inc. are in accordance with the terms set forth by the NY State Liquor Authority.
I agree to pay interest at a rate of 1.5% per month (18% per annum) for all invoices past due, and all reasonable costs of collection, including attorney’s fees, in the event of my failure to pay. In consideration of the receipt of services by said firm, we the undersigned do hereby jointly and severally guarantee the payment to said firm. This is your authority to charge 1.5% per month (18% per annum) on all past due amounts. I/We the undersigned do also hereby agree that if default of payment shall be made by the said debtor’s account, past or future, in accordance with the terms of credit, that we will make the said payment or any balance due thereon, and do jointly guarantee the payment of the said account any balance due on same, plus interest and cost of collection fees if necessary. I/We hereby waive notice of non-payment of the said account by the said debtor and notice of failure of collection of the same. *

I Agree

I Do Not Agree

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First & Last Name (This Serves As Your Digital Signature) *Please fill the required field.

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