Contact Person's Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred Methods of Payment *

The following are the payment method we accept. Please choose your preference. Should you choose "CC", we will reach out via phone to collect your CC info and enter it straight into our payment system so it is securely kept on file. For your security, we never write down your CC info. Once it is entered into our secure payment system, no one can see the info except the last 4 digits of your CC #.

eTransfer

Direct Deposit

Mailing of Cheque

Credit Card [VISA / MASTERCARD] - 4% CC Processing Fee Applies

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping Address *

Please type it out again even if it is the same as Billing Address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Kombucha Format *

We offer Happy Belly Kombucha in 2 formats. One is served on draught, which is sold in keg format. And the other is in can format. Please choose the format(s) that you are interested in carrying.

Can

Keg

Estimated Start Date *

Please let us know when you would like to start carrying Happy Belly Kombucha product.

MM

DD

YYYY