Reseller Application Form

Contact Information

Business Name:

Registered Business Address:

City:

State/Province:

Country:

Business Registration Number:

Year Established:

Website:

Social Media Handles (Facebook, Instagram, LinkedIn, etc.):

Primary Contact Name:

Job Title:

Phone Number:

Preferred Method of Contact:

Type of Business (Select all that apply): Retailer Distributor Wholesaler Online Store Other

Primary Market/Region Served:

Current Product or Brands Distributed:

Reference 1:

Reference 2:

How do you plan to market and sell our products?

Do you have a dedicated sales team? Yes No

Describe your target customer base:

I hereby confirm that all information provided is accurate and up-to-date. I agree