New Customer Application

GENERAL BUSINESS INFORMATION

Business Model: (check all that apply)

Distributor
Retailer
E-Commerce
Manufacturer

Name

First

Last

Primary Business Type:

Business Name (Full Legal Name)

Click here if DBA is the same as Legal Business Name

Click here if DBA is the same as Legal Business Name

D/B/A or Trade Name (if any)

Primary Phone #

Secondary Phone #

Email

Website / URL

Click here if shipping address is a residential address

Click here if shipping address is a residential address

Shipping Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

shipping or Name

Click here if billing address is different from shipping address

Click here if billing address is different from shipping address

Billing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Additional Information