Retailer Application Form

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? *

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