Reseller Application | Apply Online To Become A Reseller

Contact Information

Company Name *

DBA

First Name *

Last Name *

Phone *

Email *

Website

Billing Address

Address Line 1 *

Address Line 2

City *

State/Province/Region *

Postal/Zip Code *

Country *

Shipping Address

Address Line 1 *

Address Line 2

City *

State/Province/Region *

Postal/Zip Code *

Country *

Business Information

Type of Organization *

Date Established

Federal Tax ID *

State Registration/Reseller Certificate # *

Will you be stocking our products?

Yes

No

Would you like to be notified of updated prices and new products by email?

Yes

No

Trade Area Information

Number of Distribution Warehouses

Number of Retail Storefronts

Trade Area

Personnel Information

Accounts Payable Contact First Name

Accounts Payable Contact Last Name

Accounts Payable E-mail

The primary buyer is the owner, president or authorized buyer of the company. Only the primary buyer and the 3 additional buyers listed here will be allowed to purchase on this account. If the Additional Buyers boxes are left blank, only the owner, president or authorized buyer will be able to purchase.

Owner or President

First Name *

Last Name *

Additional Buyer

First Name

Last Name

Additional Buyer

First Name

Last Name

Additional Buyer

First Name

Last Name

Setting Up Your Account Access

Upon approval of your application, we will set up an exclusive online ordering portal for your business. This portal will enable you to place orders, review order history, and check order status efficiently.

Email Address for Account Access

Please enter the email address you wish to use for accessing the account. Remember, only one email address can be assigned per account, and all authorized buyers will use this email to access the online portal.

Application Authorization

By typing my name below I am electronically signing this application as the owner, president or authorized buyer of the company listed above.

Owner, President, or authorized buyer's Signature required

First Name *

Last Name *

Date Signed

Your Name

Title

First Name *

Last Name *

I am a *

Validation *

Become a Reseller