Name* First Last Company* Title* Federal EIN* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Website Industry for Retail* Do you intend to sell online?* yes no Do you have a physical brick-and-mortar store?* yes no Do you work in a medical or therapeutic practice?* yes no Are you a vape/smoke shop?* yes no Estimated yearly CBD sales?*Annual Retail RevenueFlorida Businesses ONLY, please provide Sales Tax CertificateAccepted file types: jpg, png, pdf, Max. file size: 10 MB.Please upload a png, jpg or pdf. Max file size: 10MB.
