Southern Refinery
Wholesale Request Form
Name
First Name
Last Name
Email
example@example.com
Account Accepts Email Marketing
Type Yes or No In The Provided Blank
Phone Number
Please enter a valid phone number.
Phone Accepts SMS Marketing
Type Yes or No In The Provided Blank
Are you applying to be a wholesale customer?
Type WHOLESALE in the provided blank
Tags
Type WHOLESALE in the provided blank
Are you applying for TAX exempt?
Type YES in the provided blank
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: