Full Legal Name / Business Entity (required)
D.B.A. of Division of (if applicable)
Email (required)
Daytime Number (required)
Evening Number (required)
Fax Number (if applicable)
Mailing Address (required)
Street Address (required)
Company Type ProprietorshipPartnershipCorporationOther
Type of Business WholesalerRetailerMass MarketOther
Federal Tax ID
Responsible Parties (Owners, Partners of Officers) Full Name (required)
Home Address (required)
Full Name
Home Address
Please upload your resale tax certificate if applicable.