First Name*

Last Name*

Job Title*

Email*

Phone Number*

Business Name*

Business DBA (optional)

Street Address*

Address 2

City*

Region / State*

Post Code*

Country* USA Canada Mexico

Business FEIN Number*

Number of Locations*

Tobacco Sales License*

(PDF, PNG, JPG only)

Business License*

(PDF, PNG, JPG only)

I am a tax-exempt reseller

Sales Tax Exemption Certificate*

(PDF, PNG, JPG only)

I agree to the terms and conditions*

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