Retailer Application Form

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Add some items to your cart and then try checking out.

Thank you for your interest in becoming one of our retailers!

Please complete the form below. Information provided will be kept confidential.

Company Name *

Store Name *

Store Address (street) *

Store City *

Store Province *

Store Postal Code *

Store Phone *

Store Fax

Store Email *

Business Licence # *

Owner Name *

Owner Address (street) *

Owner City *

Owner Province *

Owner Postal Code *

Home Phone *

Owner Cell

Is your store open? *

Yes

If yes, how many years has it been established?

If no, when do you plan on opening?

How many locations to you have? *

Type of Store *

Merchandise *

Name 3 well-known brands that you carry or plan to carry *

Name of closest competing retailer(s) in your proximity and approx. distance *

Do you have a website? If yes, website address *

Which of our products are you interested in? *

How did you hear about us? *