RETAIL REGISTRATION

Retailers, please fill out application completely and submit along with a copy of Current Tobacco Resale License. Once Application is received and processed you will receive a Retail Customer Number. Please utilize this number to Login and View your Account and Place Orders.

LOCATION INFORMATION

Business Name
Date Established
Number of Retail Stores
Address
City
State
Zip
E-Mail of Business
Company Website
Business Telephone
Name of Person primarily responsible for this Business and placing orders:
Name:
Title:
Telephone
Mobile

TAXPAYER INFORMATION

Federal TaxID Number
Legal Name of Entity (Sole Owner or Partners: First Name, Middle Initial and Last Name; Corporation or Other Name)
Mailing Address of Business if different from above:
Address
City
State
Zip
Name & Telephone Number(s) of Person primarily responsible for this Business:
Name:
Title:
Telephone
Mobile

STATE TOBACCO PERMIT INFORMATION

Permit Number #
State Issued
Expiration Date
Upload copy of Tobacco Resale License here:


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