Vendor Application
Date
*
-
Month
-
Day
Year
Date
Company Name
*
D.B.A.
Primary Contact
First Name
Last Name
Alternate Contact
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Website
Social Media Handle(s)
MED License Number(s)
404R, 404, 403R, 403
Business Story
This will be public facing. Please use full sentences, correct grammar, and proper spelling.
Product Type
Bulk Flower
Bulk Trim
Bulk Popcorn
Pre-packaged Flower
Vape Carts
Pre-rolls
Edibles
Concentrates
Other
Are you the registered owner of the MED licensed facility?
Yes
No
Are you able and willing to send product samples to interested purchasers?
Yes
No
Are you able and willing to provide tours of your facility to interested buyers?
Yes
No
Upload a copy of your MED license here.
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Upload a copy of your local MED license here.
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Upload a copy of your Wholesale Tax license here.
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Upload a copy of your W9 here.
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