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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? NoDo You Sell Products Online? Yes

How did you hear about us?

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? NoIs 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)

Originating Website (will be hidden)

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

Permanent Address

City

Province

Postal Code

I HAVE READ AND AGREE TO TERMS AND CONDITIONS

I HAVE READ AND AGREE TO TERMS AND CONDITIONS NoI HAVE READ AND AGREE TO TERMS AND CONDITIONS Yes

Applicant Full Name

Signed By Authorized Agent/Officer

Date

Attach File

Attach a file