WHOLESALER application/ Registration Form
Customer Details:
Full Name
*
First Name
Last Name
Legal Business Name
*
Federal EIN (Employer Identification Number)
*
Business Type
Corporation
LLC
Sole Proprietor
Other
Business License Number (FFL TYPE)
*
Resale Certificate / Sales Tax Permit Number
*
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of
Website
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Please give reference of any two people whom you feel:
Rows
Full Name
Address
Contact Number
1
2
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