So glad you’re interested! ABOUT POTENTIAL CUSTOMER First Name Last Name Title / RolePlease select... Owner Territory/District Manager Brand Manager/Rep Buyer/Merchandiser Chain Manager Store Manager Cashier A/R Other MOBILE PHONE EMAIL ADDRESS COMPANY TYPE OF BUSINESS Please select... CONVENIENCE STORE STORE WITH GAS STATION MULTI-STORE OPERATOR CANDY SHOP CBD / VAPE SHOP DELI EDUCATION INSTITUTION HOSPITAL BODEGA OFFICE BUILDING TOBACCO SHOP OTHERMultiple locations? Choose the majority. Gas brand partners? Please select... MOBIL BP CITGO EXXON SHELL IRVING VALERO SPEEDWAY CHEVRON MARATHON OTHERSelect all that apply BUSINESS NAME YEARS IN BUSINESS enter #s only OFFICE TELEPHONE BUSINESS ADDRESS StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico GENERAL BUSINESS INFORMATION Have you ever worked with NCD or any of our divisions? (HLA, J Polep, Century Dist, Wustefeld)Please select... Yes No Unsure Welcome back! Tell us which Division?Please select... Allen Brothers / Philly J Polep / Chicopee Harold Levinson Associates (HLA) / Farmingdale Colonial / Tampa Century Distributors / Rockville Wustefeld Multiple! Unsure How many locations do you have?Please select... 1 2 - 4 5 - 9 10 - 19 20-49 50-99 100-199 200+ CURRENT PRODUCT SPECIFIC OFFERINGS COFFEE Do you currently offer a COFFEE / HOT beverage program?Please select... Yes No Unsure If yes, which coffee brand is most prominent in your store(s)?Please select... Baronet Bean Town Caribou Chock Full 'O Nuts Green Mountain Illy Island Coffee Lavazza Nespresso New England Coffee Peet's Starbucks Other Unsure NONE Approximately, how many pounds of coffee per week do you sell? Other FOOD SERVICE POTENTIAL Interested in learning about our CHICKEN program?Please select... Yes No Unsure Interested in learning about our PIZZA program?Please select... Yes No Unsure Interested in learning about our ROLLER GRILL program?Please select... Yes No Unsure Interested in our SANDWICH/GRAB GO program?Please select... Yes No Unsure Interested in learning about our UNCLE ED's PASTRY, SNACKS or CONFECTION ITEMS?Please select... Yes No Unsure TOBACCO / OTP Interested in learning about our PREMIUM CIGAR program?Please select... Yes No Unsure Approximately, what is your weekly cigarette carton count? enter #s only GENERAL QUESTIONS Select all of the delivery services you participate in, if any.Please select... None DoorDash Go Puff GrubHub Lula Postmates Seemless Self-Delivery Uber Eats Other Do you participate in any Distributor accrual programs?Please select... Yes No Unsure Does the store have digital signage/TVsPlease select... Yes No Unsure Anything else you want to share? How did you hear about NCDPlease select... NCD Catalog
National Convenience Distributors