Become a Dealer

Distributor Application Form

Acceptance is subject to approval
Primary Contact Name*

First NameLast Name
Job Title*
E-mail*
example@example.com
Phone*
Format: (000) 000-0000.
Tag

Business Contact Information
Company Name*
Name of Business
Company E-mail*
example@example.com
DBA's Used*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Information
Company Website
Date Established*

MonthDayYear
Date
Business License #*
Federal Tax ID #*
Upload Business License*

Cancelof
Upload Resale Permit

Please attach company resale permit to expedite process
Cancelof
E-Commerce WebsiteConsultancySingle Store/LocationMultiple Stores/Locations

Sales Information
Highest Priced Retail Product:*
Dollar amount
Number of These Units Sold Quarterly:*
DispensariesCultivators/ProducersProcessors/ManufacturersOther
Please describe how your company handles customer service needs (i.e. size of customer service team, hours and availability, methods of contact, etc.): *

References

Please enter three business trade references
- Company Name*
- Contact Name *
- Phone Number*
- Email Address*
- Company Name*
- Contact Name *
- Phone Number*
- Email Address*
- Company Name*
- Contact Name *
- Phone Number*
- Email Address*
- The information provided in this application shall not be shared to anyone else and is kept confidential.
- Yes
- Signature
- Should be Empty: