Distributor Application Form

B2B Registration Form

Please fill out the following form to register as a B2B customer.
Business Information
Store Name*
Business name*
Business Website (optional)
Year Founded*
Contact Information
Contact Name*

First NameLast Name
Title/Position*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
EIN:*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How customers order from you:*

Physical Store onlyOnline Store onlyBothNot ordering yet
Professional license required to purchase from your store?:*

Yes, requiredNo, not required
Does your store has more than 1 location:

YesNo
Do you currently work with sub-distributors:*

YesNo
Opening order at least $5000 is required to setup the B2B account. Would you able to meet this? :*

YesNo
To maintain the account status, minimum annual order value $20,000 is required. Would you able to meet this? :*

YesNo
Describe yourself and your business:*
Should be Empty:

B2B Registration Form