Retailer Signup

If you are an e-commerce, vape shop or home business you will not be approved for partnership. Only natural retail and medical locations are being accepted. Our Original Formula (formerly Advanced) concentrations are not available thru direct wholesale, retail, or distribution channels. 
 
Retailer Application: Please allow up to 14 business days for all retail applications to be processed.
First Name*
Last Name*
Title*
Company*
Federal EIN (If UK/EU, use VAT Number)*
Industry*
Do you intend to sell products online?*
Do you have a physical brick and mortar store that you intend to sell products in?*
Are you part of a medical or therapeutic practice?*
Are you a vape/smoke shop?*
Website
Phone*
Email*
Business Address*
City*
State*
Zip Code*
Country*
How did you hear about us?*
If other, please specify:
If referred by another company, please list it (Referral codes here)
Estimate Yearly Sales Interest*
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