Authorized Wholesaler Application

Contact Information

Contact First Name *

Contact Last Name *

Contact Email *

Contact Phone *

Phone Number FormattingFormat: (111-111-1111)

Contact Role *

Shipping Address (Line 1) *

Shipping Address (Line 2)

Shipping Country *

Shipping City *

Shipping State *

Shipping Zip Code *

Billing Information

Business Name *

Business Email *

Business Phone *

Phone Number FormattingFormat: (111-111-1111)

Billing Address (Line 1) *

Billing Address (Line 2)

Billing Country *

Billing City *

Billing State *

Billing Zip Code *

UPS Shipper Code

What does this mean?Maximum 6 digits; No spaces or dashes.

Retail Sales Certificate #

Select a file to upload...

Issuing State

FEIN Number

Buying Group Affiliation

Type of Business

Login Information

Username *

Creating a UsernameMinimum Requirements: Must be at least 6 characters long and may only contain letters, numbers, and the following symbols: dash (-), underscore (_), period (.), and the at sign (@).

Password *

Creating a PasswordMinimum Requirements: Must be 8-20 characters long and must have at least one upper case letter, one lower case letter, one number, and may not contain these characters: -, <, >, |, ~, !, ;

Confirm Password *

Security Code *

Please help us prevent fraudulent activity.

Authorized Wholesaler Application

Contact Information

Billing Information

Login Information

Activity