RETAILER INTEREST FORM ABOUT YOU Your First Name Your Last Name Your 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. Who are your 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... J Polep Harold Levinson Associates (HLA) Century Distributors 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+ BUSINESS SOCIAL MEDIA PRESENCE Working with NCD means a true partnership full of support and engagement. Let us know where we can help customer's find you! WEBSITE URL TWITTER @ INSTAGRAM @ FACEBOOK URL SNAPCHAT @ YOUTUBE @ CURRENT PRODUCT SPECIFIC OFFERINGS In order to route your interest to the best sales consultant, please answer the following: 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 Are you interested in learning about our CHICKEN program?Please select... Yes No Unsure Are you interested in learning about our PIZZA program?Please select... Yes No Unsure Are you interested in learning about our ROLLER GRILL program?Please select... Yes No Unsure Are you interested in our SANDWICH/GRAB GO program?Please select... Yes No Unsure Are you interested in learning about our UNCLE ED's PASTRY, SNACKS or CONFECTION ITEMS?Please select... Yes No Unsure TOBACCO / OTP Are you 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 Do you have digital signage/TVs in your store(s)Please select... Yes No Unsure Are you happy with your POS provider?Please select... Yes No I don't have a POS system Unsure Anything else you want to share? Contact Information
