Resnick New Customer Application

Resnick Distributors Would Like To Do Business With You!

To get started, please fill out the form below and tell us about your business.
Referral Code
First Name*
Last Name*
Cellphone Number*

Area CodePhone Number
Email Address*
Store Name*
Store Address (where products are delivered)*

Street Address

Street Address Line 2

CityState

Zip Code
Convenience StoreDeli/ConvenienceTobacco/Smoke ShopGas/ConvenienceTravel RetailPharmacyLiquorE-CommerceOther
How did you hear about us?
What is your other store's 6-digit Resnick Customer #?*
If you have multiple stores, please add all.
Is there a Resnick Sales Rep. you're already working with?*
Select "None" if the answer is no or you don't recall their name.
Any comments or information you would like to add:
I would like to fill out the complete business application right now and get startedI just want to submit the above information and have someone contact me
Resnick Distributors

www.resnickdistributors.com Phone: 800-828-3865 Fax: 732-296-6648
Resnick Use Only
Entity Legal Name*
EIN# (Federal Tax ID)*
YesNo
Entity Legal Address*

Street Address

Street Address Line 2

CityState

Zip Code
Number of Locations
Years In Business
Business Credit Application:

Please complete the application below by entering the information requested. Resnick Distributors respects your privacy and is committed to protecting it at all times. We only collect information necessary to qualify for credit.
Principal Information
First Name*
Last Name*
Title
Principal Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number*

Area CodePhone Number
Principal Cellphone Number*

Area CodeCell Number
Principal Social Security #*
YesNo
Principal #2 Information
Principal #2 Name

First NameLast Name
Principal #2 Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Principal #2 Cellphone Number

Area CodePhone Number
Principal 2 Social Security #
What is the approx. weekly dollar amount you are planning to purchase from Resnick?*
What company is your Current Primary Supplier?*
We encourage you to upload required documents to expedite your approval.

However, we will email you a link to continue later if you don't have all the documents handy right now. All documents for your particular state are required and will be listed below once the state is chosen from the dropdown menu.
What State is Your Store Located In?*
The documents we require are based on your answer above
NEW YORK

1) Your Driver's License
2) IRS Federal EIN# Letter or SS-4 Form.
If not, a signed W-9 Form with Federal EIN# entity legal name.
3) Sales and Use Tax Resale Certificate ST-120 Click To Download
4) Certificate of Authority
5) Cigarette/Tobacco License (if applicable)
6) Voided Check
NEW JERSEY

1) Your Driver's License
2) IRS Federal EIN# Letter or SS-4 Form.
If not, a signed W-9 Form with Federal EIN# entity legal name.
3) Sales Tax Resale Certificate Form ST-3 Click To Download
4) Certificate of Authority
5) Cigarette/Tobacco License (if applicable)
6) Voided Check
PENNSYLVANIA

1) Your Driver's License
2) IRS Federal EIN# Letter or SS-4 Form.
If not, a signed W-9 Form with Federal EIN# entity legal name.
3) Exemption Certificate REV-1220 Click To Download
4) Sales Tax License or Business Registration/PA Entity Registration
5) Cigarette/Tobacco License (if applicable)
6) Voided Check
CONNECTICUT

1) Your Driver's License
2) IRS Federal EIN# Letter or SS-4 Form.
If not, a signed W-9 Form with Federal EIN# entity legal name.
3) General Sales & Use Tax Resale Certificate Click To Download
4) Sales and Use Tax Permit
5) Cigarette/Tobacco License (if applicable)
6) Voided Check
TEXAS

1) Your Driver's License
2) IRS Federal EIN# Letter or SS-4 Form.
If not, a signed W-9 Form with Federal EIN# entity legal name.
3) Sales & Use Tax Resale Certificate Click To Download
4) Sales and Use Tax Permit
5) Cigarette/Tobacco License (fill in permit #'s below if applicable)
6) Voided Check
TX Cigarette/Tobacco Permit #
(if ordering cigarettes and/or tobacco)
TX E-Cig Permit #
(if ordering e-cigarettes)
Click Below To Upload Files or Drag and Drop Them. (Please double-check expiration dates on forms before submitting).

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By submitting this application you hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended.
After submitting, we will email you a link to continue later if you have not completed in full. Thank You!
Plainfield Tobacco and Candy Co., Inc t/a Resnick Distributors

25 Van Dyke Ave. New Brunswick, NJ 08901 Phone: 800-828-3865 Fax: 732-296-6648
Account #
Sent Date

MonthDayYear
Date
Credit Score

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Completed Contract

Cancelof
Terms (per Jonathan)
YesNo
Should be Empty:

Resnick Distributors Would Like To Do Business With You!

Resnick Distributors

Business Credit Application:

Principal Information

Principal #2 Information

After submitting, we will email you a link to continue later if you have not completed in full. Thank You!

Plainfield Tobacco and Candy Co., Inc t/a Resnick Distributors