New Dealer Form

Regal Lager Authorized Dealer Agreement
Legal Business Name:*
Store Name or DBA:*
Business Entity:*
FEIN (Canadian Enterprises use CRA Business Number):*
Sales Tax Resale ID (Canadian Enterprises use Provincial Tax ID):*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address Type
Address Class
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address Type
Address Class
Store Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address Type
Address Class
For multiple stores and/or warehouse locations please attach at the end of this form.
Principal or Owner's Name:*

First NameLast Name
Title:*
Email Address for Sales Order Confirmations*
Phone Number*
Email for Shipment Confirmations*
Phone Number*
Email for Invoices and Receipts*
Phone Number*
Email for Customer Service*
Phone Number*
Email for Individual Completing this Form*
Phone Number*
Website
Are you a member of Brixy?*

YesNo
Credit Card Number*
Credit Card information is being submitted using an encrypted system.
Expiration Date*
CVV*
Credit Card Authorization:

By clicking Submit on this form, I authorize REGAL LAGER, INC. to charge my Credit Card account for the full purchase amount on the full amount due for products and related charges purchased from them. Nothing herein shall be construed as a waiver of any rights or remedies REGAL LAGER, INC. may have with respect to collecting any amounts due on account of Retailer.
Document Upload

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I have read the below Minimum Advertised Price (MAP) Policy:*

Yes
I have read and understand the Regal Lager, Inc. Authorized Dealer Agreement and by my authorized signature below agree to be bound by its terms.
Signature*

Clear
Please verify that you are human*
Regal Lager, Inc. Minimum Advertised Price Policy
Regal Lager Authorized Dealer Agreement
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Country/region

New Dealer Form

Regal Lager Authorized Dealer Agreement