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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