New Account Forms Thank you for your interest in becoming a customer of Southern Glazer's Wine & Spirits of Nevada

Please download, complete and submit the following forms to:

• New Account Credit Agent Michon Wrighto NVNewAccounts@sgws.com o (775) 353-5320o (702) 492-4257, efax - secure line

1. Credit Application Form 2. Continuing Guarantee Form 3. Nevada Tax Exempt Resale Certificate 4. Nevada Tax Exempt Resale Certificate (EXAMPLE) 5. Customer Pick-up Authorization Instructions 6. Customer Pick-up Authorization Form 7. Automatic Payment Plan (CHEXpedite)

Please feel free to contact Michon at your convenience if you have any questions or concerns. We look forward to doing business with you.

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8400 S JONES LAS VEGAS, NV 89139

1170 S ROCK BOULEVARD RENO, NV 89502 Phone: 775-353-5320 Fax: 702-492-4257Email: NVNewAccounts@Sgws.com

CREDIT APPLICATION

BUSINESS INFORMATION:

Phone:Number of Years in Community: Amount of Credit Requested:If Business Incorporated, under Law of which State: Date Incorporated:Name on Liquor License: _____________________________________ Liquor License #:

Name Address State Zip Code Phone #

OWNER INFORMATION:Owners Name: SS#:Spouses Name : SS#:Owners Home Address and Phone(include City, State and Zip Code:

Other Businesses Owned (Previously and Presently):Real Estate Owned: ________________________ Value $: _______________ Mortgage: ______________ Amount Owed: ____________Establishments' Landlord's Name, Address(include City, St and Zip): ____________________________________ Phone: ____________Machinery and Equipment in Establishment: _____________________________ Value $ _________Liens Held By: _________________Have you ever filed Bankruptcy? ____________ Any Lawsuits Pending? ___________ Business Bank Reference: _________________________ Name of Account: ______________________ Acct#: _____________________Personal Bank Reference: ________________________ Name of Account: ______________________ Acct#: _____________________

TRADE REFERENCES: (minimum of 3 required)NAME ADDRESS (INCLUDE CITY, STATE AND ZIP) PHONE ACCT# CONTACT NAME

Phone: Fax:

Check Here If Same As Above

Street Address: City: ______________State: _____ Zip:_________AP Contact Name

CityName, Address and Phone Number of all Proprietors and Corporate Officers:

Statements are to be mailed to the following address for payment:

Street Address:

Fax: # of Locations: City: State: Zip:

Name of DBA:

Federal Tax ID:Social Security:

Type of Business: Year Established:

Establishment:

Todays Date:THIS APPLICATION MUST BE COMPLETED BY THE PARTY RESPONSIBLE FOR PAYMENT

Corporation/LLC Partnership Sole Proprietor Liquor Licensee

Authorized SGWS Signature Printed Name & Title Date

Authorized Client Signature

Conditions of Sale and Terms of Payment: Applicant represents that Applicant has read, understands and consents to the provisions of the Credit Agreementset forth on the following pages of this Credit agreement. Applicant authorizes investigation and disclosure of information of credit application including checkingcredit history with credit bureaus and others. All payments will be expected in accordance with NRS 369.485, otherwise COD will be expected. I understand thatdelinquent payments may jeopardize my credit privileges. Both pages of this credit application must be signed in order to be approved for credit.

Printed Name & Title Date

______________________________

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Nevada Statutes NRS 369.485 requires payments by customer before or on the 10th day of the month followingdelivery of product. Unpaid deliveries will result in customer becoming delinquent on the 15th of the monthfollowing the month of delivery and Southern Glazer's Wine and Spirits shall charge the customer that is delinquent aservice charge of 1.5% of the amount of the unpaid balance. Customer account will be placed on delivery hold forpayments not received by the 15th of the month and all future deliveries must be paid for by cash, money order,certified check or cashier's bank check until account is paid in full. Short paying of invoices is prohibited. Creditfor invoices or pricing errors or returns will be issued to your account and will appear on your monthly statements.

An approved liquor license is necessary in order for Southern Glazer's Wine and Spirits to release your order. The fastestway for Southern Glazer's Wine and Spirits to verify license status is for our customer to fax it to the number provided onthe first page of this credit application. A copy of actual license and resale must be received with 30 days of opening order.Nevada Statutes NRS 369.487 requires all retailers to purchase liquor only from state-licensed wholesalers andNRS 369.488 provides the sources for purchase of liquor by retailer.

Authorized Client Signature Printed Name & Title Date:

any customer checks are returned for NSF (non-sufficient funds) the customer’s account will be placed onCash Only for 60 days and a twenty-five ($25) dollar fee will be charged. If two or more NSF checks are receivedin a 6-month period, the account will be placed on Cash Only for a minimum of 6 months.

If customer's account becomes delinquent and a payment plan becomes necessary, customer agrees to payCOD or cash for all current orders plus the amount agreed upon per the terms of payment plan. Once delinquent paymenthas been received in full under payment plan terms, customer will be on COD or Cash for a period no less than sixmonths.

By signing the Credit Application, Applicant certifies that all statements and information included in the CreditApplication are true, correct and complete. Southern Glazer's Wine and Spirits is authorized to verify all statementsthrough any source available to it and all references are authorized to release information to Southern Glazer's Wineand Spirits.Pending approval of credit and as long as customer has provided re-sale certificate current and a valid liquorlicense, Southern Glazer's Wine and Spirits may accept orders for Applicant's on a Cash or Check basis upon delivery. Ifcredit is approved, Southern Glazer's Wine and Spirits reserves the right to cancel credit at any time with or without noticefor whatever reason.

Applicant agrees that Southern Glazer's Wine and Spirits shall be entitled to rely on instructions provided by any officer,owner or employee of customer in connection with the purchase of products from Southern Glazer's Wine and Spirits andcustomer is responsible for payment of these orders. A list will be provided to Southern Glazer's Wine and Spirits ofauthorized personnel to place and pick-up orders.

Applicant agrees to pay upon demand all of Southern Glazer's Wine and Spirit’s costs and expenses, including attorneys’fees and Southern Glazer's Wine and Spirit's legal expenses, incurred in connection with the enforcement of this creditapplication should the account become delinquent. Costs and expenses include Southern Glazer's Wine and Spirit’sattorneys’ fees and legal expenses whether or not there is a lawsuit, including attorneys’ fees and legal expensesfor bankruptcy proceedings (and including efforts to modify or vacate any automatic stay or injunction), appeals,and any anticipated post-judgment collection services. Applicant also shall pay all court costs and such additionalfees as may be directed by the court.

Should customer’s account require a payment plan or should there be any NSF”s in a 6 month period, uponrequest by the customer in writing, Southern Glazer's Wine and Spirits will re-evaluate customer’s credit anddetermine appropriate credit terms.

SGWS CREDIT AGREEMENT TERMS AND CONDITIONS

In order for Southern Glazer's Wine and Spirits to extend credit to Applicant or accept check as payment for services, acredit application must be approved. This Credit Application must contain the signature of a company officer, partneror owner and all other requested information. Applicants with insufficient references or unsatisfactory credit applicationswill be required to pay cash or check upon delivery.

In compliance with Nevada Sales and Use Tax Laws, it is necessary that customers provide a signed resalecertificate with their State Sales Tax Permit Number declaring that merchandise has been purchased for re-sale.

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____________________________________________________________________________________________________________

CONTINUING GUARANTY To: Southern Glazer's Wine & Spirits of America, Inc., dba Southern Wine & Spirits of Nevada 8400 South Jones Blvd. 1170 S. Rock Boulevard Las Vegas, Nevada 89139 Reno, Nevada 89502

For valuable consideration, and to induce the extension of credit, the undersigned (hereinafter called Guarantor) absolutely and unconditionally guarantees and promises to pay to Southern Glazer's Wine & Spirits of America, Inc., dba Southern Wine & Spirits of Nevada a Corporationation (hereinafter called Company), its affiliates, successors and assigns, on order or demand, in lawful money of the United States, any and all indebtedness of ______________________________________________________________________________________ (together hereinafter called Debtor), to Company, together with interest thereon at the rates permitted by N.R.S.369.485 (4). The word “indebtedness” is used herein in its most comprehensive sense and includes any and all obligations, debts and liabilities of Debtor to Company, whether such indebtedness now exists, or is incurred hereafter, whether voluntary or involuntary, and however arising, whether due or not due, absolute or contingent, liquidated or unliquidated, determined or undetermined, and regardless whether Debtor my be liable individually or jointly with others, or whether such indebtedness may be or hereafter became barred or otherwise unenforceable or whether Debtor becomes a debtor in bankruptcy. Guarantor shall be and remain liable for all interest charged on the entire indebtedness of Debtor, together with all costs, expenses, and fees for which Debtor shall be or become liable to Company.

This is a guaranty of payment and performance and not of collection, so Company can enforce this Guaranty against Guarantor even when Company has not exhausted Company’s remedies against anyone else obligated to pay the indebtedness or against any collateral securing the indebtedness, this Guaranty or any other guaranty of the indebtedness. This is a continuing guaranty relating to any and all indebtedness, including that arising under successive transactions which shall either continue the indebtedness or from time to time renew it after it has been satisfied. This guaranty shall continue in force until 30 days after receipt by Company of written notice of its revocation as to future transactions, such notice to be sent by Certified Mail, Return Receipt Requested to Company at: 8400 South Jones Blvd, Las Vegas, Nevada 89139 or 1170 S. Rock Boulevard, Reno, Nevada 89502. The termination of this Guaranty shall not have any retroactive effect with respect to obligations of Debtor incurred prior to proper termination or incurred or contracted by Debtor within 30 days after receipt of such notice. Guarantor authorizes Company, either before or after any revocation hereof, without notice or demand and without lessening Guarantor’s liability under this Guaranty, from time to time: (a) prior to revocation as set forth above, to make one or more additional secured or unsecured loans to Debtor, to lease equipment or other goods to Debtor, or otherwise to extend additional credit to Debtor; (b) to alter, compromise, renew, extend, accelerate, or otherwise change one or more times the time for payment or other terms of the indebtedness or any part of the indebtedness, including increases and decreases of the rate of interest on the indebtedness; extensions may be repeated and may be for longer than the original loan term; (c) to take and hold security for the payment of this Guaranty or the indebtedness, and exchange, enforce, waive, subordinate, fail or decide not to perfect, and release any such security, with or without the substitution of new collateral; (d) to release, substitute, agree not to sue, or deal with any one or more of Debtor’s sureties, endorsers, or other guarantors on any terms or in any manner Company may choose; (e) to determine how, when and what application of payments and credits shall be made on the indebtedness; (f) to apply such security and direct the order or manner of sale thereof, including without limitation, any non-judicial sale permitted by the terms of the controlling security agreement or deed of trust, as Company in its discretion may determine; (g) to sell, transfer, assign, or grant participation in all or any part of the indebtedness; and (h) to assign or transfer this Guaranty in whole or in part.

The obligation hereunder are joint and several, and independent of the obligations of Debtor, and Guarantor waives any right to require Company to proceed against or exhaust Company’s remedies against Debtor or otherwise, in order to enforce this guaranty; and a separate action or actions may be brought and prosecuted against Guarantor whether action is brought against Debtor or whether Debtor be joined in any such action or actions. This guaranty may be immediately enforced by Company on the nonpayment when due of any indebtedness of Debtor. Except as prohibited by applicable law, Guarantor waives any right to require Company (a) to continue lending money or to extend other credit to Debtor; (b) to make any presentment, protest, demand, or notice of any kind, including notice of any nonpayment of the indebtedness or of any nonpayment related to any collateral, or notice of any action or nonaction on the part of Debtor, Company, any surety, endorser, or other guarantor in connection with the indebtedness or in connection with the indebtedness or in connection with the creation of new or additional loans or obligations; (c) to resort for payment or to proceed directly or at once against any person, including Debtor or any other guarantor; (d) to proceed directly against or exhaust any collateral held by Company from Debtor, any other guarantor, or any other person (including, without limitation, all waivers provided under Guarantor’s Security Agreement in favor of Company); (e) to give notice of the terms, time, and place of any public or private sale of personal property security held by Company from Debtor or to comply with any other applicable provisions of the Uniform Commercial Code; (f) to pursue any other remedy within Company’s power; (g) to commit any act or omission of any kind, or at any time, with respect to any matter whatsoever or (h) to apply any payments or proceeds received against the indebtedness in any order. Guarantor also waives any and all rights or defenses arising by

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reason of (a) any “one action” or “anti-deficiency” law or any other law which may prevent Company from bringing any action, including a claim for deficiency, against Guarantor, before or after Company’s commencement or completion of any foreclosure action, either judicially or by exercise of a power of sale; (b) any election of remedies by Company which destroys or otherwise adversely affects Guarantor’s subrogation rights or Guarantor’s rights to proceed against Debtor for reimbursement, including without limitation, any loss of rights Guarantor may suffer by reason of any law limiting, qualifying, or discharging the indebtedness; (c) any disability or other defense of Debtor, of any other guarantor, or of any other person, or by reason of the cessation of Debtor’s liability from any cause whatsoever, other than payment in full in legal tender, of the indebtedness; (d) any right to claim discharge of the indebtedness on the basis of unjustified impairment of any collateral for the indebtedness; (e) any statute of limitations, if at any time any action nor suit brought by Company against Guarantor is commenced there is outstanding indebtedness of Debtor to Company which is not barred by any applicable statute of limitations; (f) any defense given to guarantors at law or in equity other than actual payment and performance of the indebtedness or (g) any modification or change in terms of the indebtedness, whatsoever, including, without limitation, the forbearance, renewal, extension, acceleration or other change in the time the indebtedness is due or the payment terms of the indebtedness. I f payment is made by Debtor, whether voluntarily or otherwise, or by any third party, on the indebtedness and thereafter Company is forced to remit the amount of that payment to Debtor’s trustee in bankruptcy or to any similar person under any federal or state bankruptcy law or law for the relief of debtors, the indebtedness shall be considered unpaid for the purpose of enforcement of this Guaranty.

Guarantor further waives and agrees not to assert or claim at any time any deductions to the amount guaranteed under this Guaranty for any claim of setoff, counterclaim, counter demand, recoupment or similar right, whether such claim, demand or right may be asserted by the Debtor, the Guarantor, or both.

Guarantor understands and agrees that the foregoing waivers are unconditional and irrevocable waivers of substantive rights and defenses to which Guarantor might otherwise be entitled under state and federal law. Guarantor acknowledges that Guarantor has provided these waivers of rights and defenses with the intention that they be fully relied upon by Company. Guarantor further understands and agrees that this Guaranty is a separate and independent contract between Guarantor and Company, given for full and ample consideration, and is enforceable on its own terms. Until all of the indebtedness is paid in full, Guarantor waives any right to enforce any remedy Guarantor may have against the Debtor or any other guarantor, surety, or other person, and further, Guarantor waives any right to participate in any collateral for the indebtedness now or hereafter held by Company. Guarantor warrants and agrees that each of the waivers set forth above is made with Guarantor’s full knowledge of its significance and consequences and that, under the circumstances the waivers are reasonable and not contrary to public policy or law. If any such waiver is determined to be contrary to any applicable law or public policy, such waiver shall be effective only to the extent permitted by law or public policy. Guarantor agrees to pay upon demand all of Company’s costs and expenses, including attorneys’ fees and Company’s legal expenses, incurred in connection with the enforcement of this Guaranty. Company may pay someone else to help enforce this Guaranty, and Guarantor shall pay the costs and expenses of such enforcement. Costs and expenses include Company’s attorneys’ fees and legal expenses whether or not there is a lawsuit, including attorneys’ fees and legal expenses for bankruptcy proceedings (and including efforts to modify or vacate any automatic stay or injunction), appeals, and any anticipated post-judgment collection services. Guarantor also shall pay all court costs and such additional fees as may be directed by the court. This Guaranty shall not be discharged or affected in any manner by the death of Guarantor, but shall bind his heirs, executors, administrators, and assigns; should the status of Debtor change in any manner, this guaranty will continue and will cover the indebtedness of the Debtor under the new status according to the terms hereof. Guarantor makes this Guaranty personally and as an individual, and not as a corporate officer, partner or other agent of representative of Debtor or any other entity.

Guarantor hereby expressly authorized Company to obtain any and all consumer credit histories and reports concerning Guarantor, from any credit reporting agencies, at any time whatsoever, in relation to this Guaranty.

IN WITNESS WHEREOF the undersigned (have, has) executed this guaranty this ______________day of _________________, 20_____. Home Address:______________________________________ ________________________________________________ Guarantor, as an individual (Signature) __________________________________________________ ________________________________________________ (Print Name) Subscribed and sworn to before me this _________________ SSN____________________________________________ day of ____________________________, 20 ____________. ________________________________________________ Notary Public ________________________________________________ SGWS Employee (in lieu of Notary SGWS Employee can witness signature)

Nevada Tax Exempt Resale Certificate

FIRM NAME: ____________________________________________________________________________

I HEREBY CERTIFY that I hold valid seller's permit number: ______________________________________

issued pursuant to Chapters 372, 374 and 377 of the Nevada Revised Statutes; that I am engaged in the business

of selling: ________________________________________________________________________________ ;

and that the tangible personal property described in the second paragraph of this certificate, which I purchase

from: SOUTHERN GLAZER’S WINE AND SPIRITS will be resold by me in the form of tangible personal

property. I further certify that in the event any of the property is used for any purpose other than retention,

demonstration or display while I am holding it for sale in the regular course of business, it is understood that I

am required by Chapters 372, 374 and 377 of the Nevada Revised Statutes to report it and pay the tax measured

by the purchase price of the property.

Description of the property to be purchased:

Purchaser: ______________________________________________

Address: _______________________________________________

Signature of Authorized Purchaser: _______________________________________________

Date: _________________ Phone:_______________________

Tax Exempt Resale Certificate TAC 103

February 28, 2017 Dear Customer: To better serve you, we have enclosed a Customer Pick-up Authorization form. Please complete the form and return it to us for your file. All customers picking up product at our Southern Glazer’s Wine and Spirits locations will have to be listed on their Company’s authorization form and will be required to show proof of identification. Company checks issued for payment at time of pick up will be accepted as long as the signatory matches the Authorization form on file. Personal checks will not be accepted without prior verification and approval. Then two forms of identification will be required, one being a picture ID. It will be the responsibility of the Customer to keep Southern Glazer’s Wine and Spirits informed of changes in personnel on their authorization list. If you have any questions regarding this matter please contact me at 775-353-5320. Sincerely, Michon WrightNew Account Credit Agent Southern Glazer’s Wine & Spirits

Customer Pick-up Authorization

Customer Information: Name:____________________________________________________________________________________ Address: _________________________________________________________________________________ __________________________________________________________________________________ Daytime Phone: ____________________________ FAX#: ________________________________________ Responsible Party: ___________________________ Daytime Phone: _______________________________ Customer’s Bank Information: Name of Bank:_____________________________________________________________________________ Authorized signers on account: ______________________________________________________________ Company checks from the above listed account with an authorized signature will be accepted for payment of product. Personal checks will require account verification and two forms of identification, at least one picture ID. Pick-up Authorization List: Please list employees authorized to order and pick-up product for your company. Your Company will be responsible for payment for product charged to your account by an authorized employee. Please include the identifying information your employee will be presenting at time of pick-up, such as State Driver’s License, State ID, U.S. Passport, or other form of valid picture identification. Please print information clearly. Name Type of ID ID Number Employee Signature Date __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Southern Glazer'sWine and Spirits will release product only to the above listed representatives of your account. Changes or updates to this list are the sole responsibility of your Company.

Dear Valued Customer:

Southern Glazer's Wine and Spirits of Nevada strives to continuously provide the highest level of service in the industry. In an effort to better serve you, we are excited to introduce a convenient, cost-effective, and automated method for paying your invoices. It’s called the Automatic Payment Plan and it’s designed to eliminate the hassles of paying your bill by check. With the Automatic Payment Plan, you will never have to write a check, address an envelope, or lick a stamp and mail a payment. With the Automatic Payment Plan, there is no high interest rate for payment, nor will you be charged interest on a late payment since your payment will be paid on time, every time with this system.

The Automatic Payment Plan uses pre-authorized checking to automatically debit your bank account for the amount of your current monthly bill due the 10th of every month for product shipments received in the previous month if you have been granted terms. Terms are granted based on approval and receipt of your credit application as well as the personal guaranty. You also have the option to have the withdrawal on the 15th of the month so that we can ensure your payments are received in accordance with NRS 369.485.

For customers that have been granted COD terms (check or cash on delivery) we can draft your checking account for your previous delivery with the COD form. COD terms require that we have received your credit application. We can draft after your delivery, on a day of your choosing, as long as it is before your next delivery. This allows you to take advantage of any credits on your account as well as saving you the hassle of getting a check to your place of business on delivery day.

With the Automatic Payment Plan you’ll enjoy the convenience of never having to remember to pay a bill and, of always knowing that your service will continue uninterrupted. I f you have any questions about this exciting new payment system, please call our office at 775-353-5320.

To enroll in the Automatic Payment Plan, simply fill out the attached form along, with a voided check and return it with your new account forms packet or, fax it to our office at 702-492-4257. For term customers, your statement will be mailed the first business day of every month. Should you have any questions regarding the pending amount scheduled to be drafted from your bank account, please contact your assigned account representative. You can also stop the service by sending notification in writing up to 3 business days before the draft date via mail to the address below or fax to 702-492-4257.

Again, thank you for your continued business and for making Southern Glazer's Wine and Spirits your preferred vendor of choice.

Sincerely,

Michon Wright, New account Credit Agent Southern Glazer's Wine and Spirits1170 S. Rock Boulevard Reno, Nevada 89502

CHEXpedite™ Automated Payments (Paper)

Account Approval Form – Delivery Payments Save time & money by signing up for our new Automatic Payment Plan (APP). For your

convenience, and with the help of your bank, we can now automatically deduct your monthly fees from your checking account. No more checks to write! No more bills to open. No more stamps to lick. Simply complete the information below and attach a voided check. Keep in mind that the Federal Government closely regulates the banking service industry. Any money drafted from your account must first have your approval. There are stiff penalties in place to merchants or processors who abuse this system.

Banking Information

Name of Primary Bank

Name of Account

Bank Routing Number

Bank Account Number

Address On Check if different from above

NOTE: If you bank at a Credit Union, you must verify with your institution the correct bank routing and account numbers for use with pre-authorized drafts on your account. I hereby authorize a bank draft on the account designated above, not to exceed the amount of services rendered for delivery. Automated payments are not eligible for electronic collection if dishonored by my bank for non-sufficient funds (NSF) or unavailable funds. Should my bank dishonor my automated payment, a second draft will be submitted for payment by my bank one week after the original draft is returned for non-payment. I understand that an additional fee of $ 25.00 will be added to the payment to cover the cost of handling the return and resubmitting for payment. Business: Southern Glazer's Wine and Spirits

Total to be Drafted Amount of Delivery

Starting Date Immediately

Authorized Representative (Print Name)____________________________________________ Date: _____________________ Title: _____________________________________________ Authorized Representative Signature: ____________________________________________________ PLEASE FAX THIS FORM AND A VOIDED CHECK TO 702-492-4257

Company Name Address

City

State

Zip Code

Phone Number

E-Mail Address

CHEXpedite™ Automated Payments

Account Approval Form – Reoccurring Payments Save time & money by signing up for our new Automatic Payment Plan (APP). For your

convenience, and with the help of your bank, we can now automatically deduct your monthly fees from your checking account. No more checks to write! No more bills to open. No more stamps to lick. Simply complete the information below and attach a voided check. Keep in mind that the Federal Government closely regulates the banking service industry. Any money drafted from your account must first have your approval. There are stiff penalties in place to merchants or processors who abuse this system.

Banking Information

Name of Primary Bank

Name of Account

Bank Routing Number

Bank Account Number

Address On Check if different from above

NOTE: If you bank at a Credit Union, you must verify with your institution the correct bank routing and account numbers for use with pre-authorized drafts on your account. I hereby authorize a bank draft on the account designated above, not to exceed the amount of my monthly statement due the 10th of every month for services rendered the previous month. Automated payments are not eligible for electronic collection if dishonored by my bank for non-sufficient funds (NSF) or unavailable funds. Should my bank dishonor my automated payment, a second draft will be submitted for payment by my bank one week after the original draft is returned for non-payment. I understand that an additional fee of $ 25.00 will be added to the payment to cover the cost of handling the return and resubmitting for payment. Business: Southern Glazer's Wine and Spirits

Draft Frequency: Monthly

Total to be Drafted: Amount of statement

Starting Date: 10th of the month

Authorized Representative (Print Name)____________________________________________ Date: _____________________ Title: _____________________________________________ Authorized Representative Signature: ____________________________________________________ PLEASE FAX THIS FORM AND A VOIDED CHECK TO 702-492-4257

Company Name Address

City

State

Zip Code

Phone Number

E-Mail Address

CHEXpedite™ Automated Payments

Account Approval Form – Reoccurring Payments Save time & money by signing up for our new Automatic Payment Plan (APP). For your

convenience, and with the help of your bank, we can now automatically deduct your monthly fees from your checking account. No more checks to write! No more bills to open. No more stamps to lick. Simply complete the information below and attach a voided check. Keep in mind that the Federal Government closely regulates the banking service industry. Any money drafted from your account must first have your approval. There are stiff penalties in place to merchants or processors who abuse this system.

Banking Information

Name of Primary Bank

Name of Account

Bank Routing Number

Bank Account Number

Address On Check if different from above

NOTE: If you bank at a Credit Union, you must verify with your institution the correct bank routing and account numbers for use with pre-authorized drafts on your account. I hereby authorize a bank draft on the account designated above, not to exceed the amount of my monthly statement due the 15th of every month for services rendered the previous month. Automated payments are not eligible for electronic collection if dishonored by my bank for non-sufficient funds (NSF) or unavailable funds. Should my bank dishonor my automated payment, a second draft will be submitted for payment by my bank one week after the original draft is returned for non-payment. I understand that an additional fee of $ 25.00 will be added to the payment to cover the cost of handling the return and resubmitting for payment. Business: Southern Glazer's Wine and Spirits

Draft Frequency: Monthly

Total to be Drafted Amount of statement

Starting Date 15th of the month

Authorized Representative (Print Name)____________________________________________ Date: _____________________ Title: _____________________________________________ Authorized Representative Signature: ____________________________________________________ PLEASE FAX THIS FORM AND A VOIDED CHECK TO 702-492-4257

Company Name Address

City

State

Zip Code

Phone Number

E-Mail Address