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Your Contact Information

First Name*

Last Name*

Cell Phone

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Business Phone

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Job Title
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Shipping Address

Address1*

Address2

City*

State

Zip Code*

My Billing Address is the same as my Shipping Address

Billing Address

Address1*

Address2

City*

State

Zip Code*

Additional Details About Your Company

Federal Tax Id (FEIN)

Tobacco License Number

Tobacco License Expiration Date

Vapor License Number

Vapor License Expiration Date

Resale License Number

Resale License Expiration Date

What products are you authorized to sell? (A License may be required depending upon your jurisdiction.)

Tobacco

Vapor

What kind of company do you have? (Select One)

Corporation

Partnership

Sole Proprietorship

Limited Liability Company

Store Type

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State of Incorporation/Formation:

Number of Years In Business:

Products Interested In:

Brands, Products etc.

Required Documents

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