CUSTOMER / DIVISION

Are you an NCD Customer (or were a customer of one of our divisions)?

Which NCD Division services or serviced, your store(s)?

Which State(s) are your store(s) in?

TYPE OF BUSINESS

If you have multiple locations choose
the majority.

Customer / Store Name

NCD Customer Account #

If you have multiple stores, just
put one account #

Your First Name

Your Last Name

Phone #

Address Line 1

Address Line 2

City

State

Postal Code

Email address

Do you have a current & active Tobacco license

SPECIAL OFFER CODE

Have a discount, coupon or promotion code?
enter it here

INTERESTED IN

PREMIUM

Do you currently carry PREMIUM CIGARS?

Which would you like to learn more about?

Select all that apply

Which are part of your store,
if any

Select all that apply

Per month, what is your cigar (stick count not revenue) projections be per month

enter #s only

GENERAL QUESTIONS

How did you hear about NCD?

Tell us which Industry Publication/Website, Event, Employee, or Broker -
so we can thank them!

Select all of the delivery services you participate in, if any.

Do you have digital signage/TVs in your store(s)

Are you happy with your POS provider?

Anything else you want to share?