Retailer Portal Application

*Current Customers Only*

Retail Portal Website Link

TABC License *

Yes

No

Pending

Account Number *

Business Name (DBA)

Street Address

City

Zip Code *

State

Texas

Arkansas

Buyer / Agent Full Name

Phone Number *

Business #

Phone

Cell Phone # *

Phone

Email Address *

Website

Application Comments From Form

Licensee or Officer Portal Access Approval *

Approve Portal Access for Buyer or Agent

Licensee Full Name *

submitted by:

*

Send me a copy of my responses