Illinois Account Application

Legal Name

DBA

Federal Tax Identification #

Account Type RestaurantRetailer

Illinois License #

Illinois Resale Certificate #

Illinois Resale Certificate Expiration Date

Billing Address

Billing Address Line 2

Billing City

Billing State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Billing Zip

A/P Contact Name

A/P Telephone

A/P Email (for invoices)

Delivery Address

Delivery Address Line 2

Delivery City

Delivery State Illinois

Delivery Zip

Delivery hours

Delivery instructions (optional)

Wine Buyer Contact Name

Wine Buyer Telephone

Wine Buyer Email

Principal Name/Title

Martine's Wines Sales Rep (optional)

Upload a copy of your signed CRT-61 resale certificate (2MB max limit)

Please note: a CRT-61 resale certificate is different than a certificate of authority, seller’s permit, or liquor license – download a blank CRT-61 resale certificate to fill out here https://tax.illinois.gov/content/dam/soi/en/web/tax/forms/sales/documents/sales/crt-61.pdf