eDrinx™ Registration Form

This is an application for registration in the Electronic Drinks Exchange. To help us register you, you may complete this form on line. You may also print the registration form , complete it and fax it to us at 604.940.1311.
As part of the registration process, the information submitted here will be verified against information eDrinx™ obtains from the British Columbia Liquor Control and Licensing Branch.

Contact Information

Contact Name: *

Main Phone # *	Main Fax # *	Email

Establishment Information

Owner Name: * Name of Establishment: *
Shipping Address: *
City, Postcode, Province: *

Billing Address of Establishment (if Different)

Billing Address:
City, Postcode, Province:

License Information for Establishment

License No. *	Type *	Name on License *

Referred By

Name:

Phone Number:

* - indicates mandatory field

I acknowledge that I have read, understand and agree to be bound by the and .

[]