Wholesaler/Affiliate Application
Customer Details:
Company Name
*
Contact Name
*
First Name
Last Name
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
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Type of Business
*
Sole Proprietorship
Partnership
LLC/Corporation
Non-Profit/Charity Organization
How did you hear about us?
*
Please Select
Internet
Word of Mouth
Facebook
Other
Please Specify
*
Where will you be selling our products?
*
Storefront
Internet/On-Line
Single Location
Multiple Locations
Kiosk/Mall
Trade/Craft Shows
Other
Would you be interested in White Labeling?
*
Yes
No
Federal Tax ID/EIN
State Sales Tax Exemption Form (if applicable)
Browse Files
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Choose a file
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Owner/Proprietor/CEO Name
First Name
Last Name
Owner/Proprietor/CEO Phone
Owner/Proprietor/CEO Email
Buyer Name
First Name
Last Name
Buyer Phone
Buyer Email
Notes
Submit
Should be Empty: