Distributor Application Form

Please fill out the following form. We will reach out to you for any additional information that is needed.

Step 1 of 3

This field is for validation purposes and should be left unchanged.

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Company Profile

Company(Required)

Legal Business Name

DBA(Required)

Doing Business As

Telephone(Required)

Fax

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Email(Required)

Website(Required)

Business Structure(Required)

Sole Proprietorship

Partnership

Corporation

President(Required)

First Last

Payable(Required)

First Last

Buyer(Required)

First Last

Number of Employees

Date Business Established

Federal Employer Identification Number (FEIN)(Required)

Home State Sales Tax License Number(Required)

Enter "N/A" if home state is AK, DE, MT, NH, or OR.

Sales Tax License / Sellers Permit(Required)

Drop files here or

Max. file size: 1 GB.

Upload your Home State Sales & Use Tax License or Sellers Permit, issued to your business address. If your business is in AK, DE, MT, NH, or OR, upload your Business Registration with current business address. If you are based internationally, upload the applicable license or registration.

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Sole Proprietorship

Name of Owner(Required)

First Last

Address of Owner(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sales Tax License / Sellers Permit(Required)

Drop files here or

Max. file size: 1 GB.

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Partnership

Name of Partner(Required)

First Last

Address of Partner(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Title

Name of Partner(Required)

First Last

Address of Partner(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Title

Name of Partner (Required if more than 2 Partners)

First Last

Address of Partner (Required if more than 2 Partners)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Title

Name of Partner (Required if more than 3 Partners)

First Last

Address of Partner (Required if more than 3 Partners)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sales Tax License / Sellers Permit(Required)

Drop files here or

Max. file size: 1 GB.

Become A Distributor

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Bank References

Name of Financial Institution(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Checking account #(Required)

Other account #

Please upload a copy of a voided bank check

Max. file size: 1 GB.

Distributor Application Form

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Become A Distributor

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