Credit Application

To open a new account with Jandell Selections please complete the form below and we will follow up with required documents. Email Info@JandellSelections.com with any questions

Name

First Name

Last Name

License Serial #

Checkbox

I have the authority to make purchasing decisions for a licensed NYS alcoholic beverage retailer (on or off premise)

Yes

Phone

(###)

###

####

Applicant Email

Billing Contact Email

Store Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Message - Please advise what items you are interested in