Wholesale Customer Registration Form · Customer Self-Service

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Account Sign Up/Login Information

Email

***

How did you hear about us?

*

Web App

Store Information

First Name

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Last Name

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Company Name

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Phone

*

Street 1

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Street 2

*

City

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State

*

Zip/Postal Code

**

Country

*

Business Type

Smoke Shop

Cigar / Tobacco Store

Convenience Store

CBD / Wellness Store

Dispensary

Cultivator / Extractor

Online Seller/Marketplace

Tax Information

FEIN Federal Tax #

**

Provincial/State Retail Sales Tax Id

*

Provincial/State Retail Sale Tax Expiration Date

*

Tobacco License Information

Do you have a Tobacco License?

Tobacco Tax License Id

*

Tobacco License Expiration Date

*

Vape License Information

Do you have a Vape License?

Vape License Id

*

Vape License Expiration Date

*

Dispensary License Information

Do you have a Dispensary License?

Dispensary License Id

*

Dispensary License Expiration Date

*

Cultivator License Information

Do you have a Cultivators License?

Cultivator License Id

*

Cultivator License Expiration Date

*

Extractor License Information

Do you have a Extractors License?

Extractor License Id

*

Extractor License Expiration Date

*

First Nations/Native American License Information

Do you have First Nations/Native American Tax?

First Nations/Native American Tax Id

*

First Nations/Native American Tax Expiration Date

*

PROPRIETOR/OFFICER INFORMATION

Proprieter/Officer Legal Name

**

Proprieter/Officer Position

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TERMS AND CONDITIONS

I have read and agree to the Terms and Conditions

*

Signed By (Applicant Name)

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