Username *

Email address *

Password *

Country *Select a country / region…Dominican RepublicGuamPuerto RicoUnited States (US)United States (US) Minor Outlying IslandsVirgin Islands (US)

State * Select an option…AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)

First name *

Last name *

Company *

Website

Telephone *

Cell Phone

Business Type * Choose one Distributor Smokeshop Vape Shop Convient Store Gas Station Retail Store or Market Other

How did you hear about us? * Choose oneEmail Blast Google Referral Tradeshow Postcard Instagram B2B Wholesale Magazine Other

This address MUST match the address on your tobacco license, as required by law! *I am entering the address for my tobacco license, and understand this is where shipments must be sent.

Address 1 *

Address 2

City *

Postcode *

EIN Number * Enter your EIN number. If you do not have one, you can obtain one from the IRS. If you do not have an EIN, you may submit your Social Security # and a W-9.

Enter your EIN number. If you do not have one, you can obtain one from the IRS. If you do not have an EIN, you may submit your Social Security # and a W-9., in a .pdf or .jpg or .png format.*

Business License Number * Enter your Business License number.

Please upload your business license if you have one, in a .pdf or .jpg or .png format.*

State Seller's Permit Number * This is called a Retail Tax ID in some states.

Please upload your seller's permit/retail tax ID in a .pdf or .jpg or .png format.*

Tobacco License Number *

Please upload your tobacco license in a .pdf or .jpg or .png format.*

Tobacco License Expiration * The expiration date must match the uploaded license.

Tobacco License Type * Choose one Retail Wholesale Distributor Manufacturer

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