First Name *
Last Name *
DBA Business Name
Email *
Phone
Billing Address Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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Do you have a Reseller Certificate? * YesNo
Do you sell products in physical locations? * YesNo
Number of Kiosks
Number of Stand Alone Locations
Do you Sell Online? * YesNo
If so, list all websites, online storefronts, etc. Separate by comma.
Do you sell on Amazon, Ebay, Alibaba, or similar websites? * YesNo
List all applicable reseller account numbers, with reference to each website, separated by commas.
Do you purchase from a distributor? * YesNo
If so, list all Distributors you purchase from. Separate by comma.
