Cigar Reps

    Salesman # ( For Office Use Only )
    Date:
    Assigned Account # ( For Office Use Only )
    Ship to Name:
    Street Address:
    City:
    County:
    State:
    Zip Code:
    Phone number:
    Fax number:
    Online ordering:
    Enter email address:
    Invoices via email:
    Enter email address:
    Statements via email:
    Enter email address:
    Bill to Name:
    Website:
    Bill to address:
    A/P Contact:
    A/P phone #:
    Cigarette License (DLN)#:
    State Tax License #:
    Other Tobacco Products License (If applicable):



    FOR OFFICE USE ONLY
    FOR OFFICE USE ONLY
    Must be completed by salesman before number can be issued:
    Assigned delivery day: _________________
    Truck: _________________
    AWI __
    Misc. ______________
    Store type: ______________
    Recommended Terms: _______
    Pricing Schedule: ______
    APPROVAL: ______________
    Anticipated Weekly volume $ ______________________
    Anticipated Weekly Carton volume # ______________________





    I (Name): , as
    (Title) for
    (Company name)
    hereby authorize L.J. Zucca Inc. to charge the credit card named below for purchasc(s) made to L.J. Zucca Inc.

    CHECK ONE

    CREDIT CARD INFORMATION

    Card Name:
    ( Last 4 Digits )Account Number:
    Expiration Date:
    CVV (code)
    Account Holder's Name:
    Account Holder's Phone:
    Billing Address:
    City:
    State:
    Postal Code:
    Authorized Account Holder Signature
    Date: