credit_application

Credit Application

Please fill out this form and mail to:
New Hampshire State Liquor Commission
Attention: Accounts Receivables
P.O. Box 503
Concord, NH 03301-0503
Phone# (603) 271-2353 Fax# (603) 271-2375

Under the authority of RSA 176:14, RSA 178:26 I-V and RSA 179:57 and Liquor Administrative Rules Chapter 900 pursuant thereto I Request credit privileges with the NHLSC in the amount of for the following establishment:

License Number:
Business Name:
Business Address:
City :
State:	Zip :
Billing Address:
City :
State:	Zip:
Type of Business:	Sole Owner Partnership Corporation
Years in Business:
Contact Name:
Telephone Number:
Fax Number:
E-mail address:
Dunn/Bradstreet#:

I certify that the above information is correct and that neither the business applying for credit or any principals or owners thereof is currently involved or has ever filed for bankruptcy as an individual or as a principal of a business. I understand that credit is assigned by license number. Should I obtain a new license number for any reason, I must reapply for credit.

* If there has been a previous bankruptcy, please forward all details with this application.

Print Name:
Title:
Signature:
Date:

Authorized Signature Form