New Retail Partner

If you have any questions please contact the rep that sent this to you.
If you do not have the contact information for your reps please call.

Your Representative
or
Trent Frisina
Director of Sales
949-424-9231

Legal Business Name*

DBA

Primary Contact Name*

Primary Contact Email*

Primary Contact Phone Number*

Receiving Manager Contact*

Receiving Manager Email*

Receiving Manager Phone Number*

Preferred Contact Method For Delivery Confirmation*

Business Address*

City, Zip*

Delivery Address
If different than store address

Delivery City, Zip
If different than store address

Receiving Hours (AM/PM)*

What type of license do you hold?*
RetailRetail/DeliveryDistributionMicrobusinessOther

Attach License*

Attach Sellers Permit*

Payment Method*

Payment Terms*

Federal EIN Number (Tax ID)*

Name
If person submitting this form is different than primary contact

Email Address
If person submitting this form is different than primary contact

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