Retailer Application

Company Name (required)

Address (required)

City (required)

Province/State (required)

Postal Code/Zip (required)

Primary Contact Person (required)

Primary Contact Phone (required)

Primary Contact Email (required)

Website

Nature of Business

Year Established

Business Category, check all that apply (required)

ResellerRetail/Store FrontOnline SalesMobile Retailer

Do you sell at trade shows? If so, which shows/events? (required)

Do you advertise? If so, where and how often? (required)

To help reduce spam, please answer the question below.

Which is bigger, 56 or 32?

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