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Contoso, Ltd.
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Application Form
Application Form
Store Information
Company Name
*
*
Main Contact Name
*
*
*
First Name
Last Name
Phone #
*
Email
*
*
*
Website
*
Contact Phone #
*
Do You Sell Products Online?
Do You Sell Products Online?
No
Do You Sell Products Online?
Yes
How did you hear about us?
*
Trade Show
Direct Mail
Web Search
Social Media
Referral
Brand Referral
Email
Shipping Address Information
Shipping Street 1
*
Shipping Street 2
*
Shipping City
*
Shipping State/Province
*
Shipping Postal Code
*
Shipping Country/Region
*
Is Billing same as Shipping?
Is Billing same as Shipping?
No
Is Billing same as Shipping?
Yes
Billing Address Information
Billing Street 1
*
Billing Street 2
*
Billing City
*
Billing State/Province
*
Billing Postal Code
*
Billing Country/Region
*
Business Type (Check all that apply)
Smoke Shop
CBD / Wellness Store
Cultivator / Extractor
Convenience Store
Cigar / Tobacco Store
E-Cig / Vapor Store
Dispensary
Online Seller/Marketplace
Other
*
Tax Information (Please attach a copy of all applicable licenses)
Provincial/State Retail Sales Tax #
*
Provincial/State Retail Sale Tax Expiration Date
*
FEIN Federal Tax# (US Only) (will be hidden)
*
Greenlane Business Unit (will be hidden)
US
CAN
EU Approved
EU Non Approved
Australia/New Zealand
Africa
South America
Brazil
Japan/China
Originating Website (will be hidden)
wholesale.greenlane.com
smokegroove.com
GNLN.ca
davincivaporizer.ca
davincivaporizer.com
davincivaporizers.eu
wholesale.gnln.eu
wholesale.gnln.com
wholesale.gnln.nl
wholesale.gnln.fr
conscious-smart.com
conscious-smart.eu
conscious-smart.nl
conscious-smart.fr
ca.greenlane.com
canada.vapor.com
eycemolds.com
gethyer.com
Gpen.com
Gpen.ca
greenlane.com
haringglass.com
higherstandards.com
marleynaturalshop.com
puffitup.com
smokegroove.com
thefirefly.com
Vapium.com
Vapium.ca
vapor.com
vapesandparts.com
vaporizerdepot.com
vibespapers.com
eu.greenlane.com
Tobacco Tax Information (Please attach a copy of all applicable licenses)
Do you have Tobacco License?
Tobacco License #
*
Tobacco License Expiration Date
*
Dispensary Tax Information (Please attach a copy of all applicable licenses)
Do you have Dispensary License?
Dispensary License #
*
Dispensary License Expiration Date
*
Vape Tax Information (Please attach a copy of all applicable licenses)
Do you have a Vape License?
Vape License #
*
Vape License Expiration Date
*
First Nations/Native Ammerican Tax Information (Please attach a copy of all applicable licenses)
Do you have First Nations/Native American Tax?
First Nations/Native American Tax ID #
*
First Nations/Native American Tax Expiration Date
*
PROPRIETOR / OFFICER INFORMATION
Full Legal Name
*
Position
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Permanent Address
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City
*
Province
*
Postal Code
*
I HAVE READ AND AGREE TO TERMS AND CONDITIONS
*
I HAVE READ AND AGREE TO TERMS AND CONDITIONS
No
I HAVE READ AND AGREE TO TERMS AND CONDITIONS
Yes
Applicant Full Name
*
Signed By Authorized Agent/Officer
*
Date
*
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