Wholesale Business Information Form

Wholesale Business Information Form

Please provide your business and compliance details for onboarding and approval.
Legal Business Name
DBA (if different from Legal Business Name)
Business Type
State(s) of Operation
Business Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Name

First NameLast Name
Contact Title / Role
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
State Issued Resale / Sales Tax ID #
Upload Resale Certificate (PDF or photo)

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Alcohol License # (if applicable)
Distributor License # (if applicable)
State(s) Authorized to Sell THC Beverages (if applicable)
Interested In
Estimated Initial Order Size
Target Launch Date

MonthDayYear
Date
Authorized Signer Name

First NameLast Name
Authorized Signer Title
E-Signature
Date Submitted

MonthDayYear
Date
Should be Empty: