Request Wholesale Account

Please fill in the following form to be able to place wholesale orders.

Name*:

Business Name*:

Contact E-mail*:

Contact Phone*:

Business Address*:

City*:

State*:

Zip Code*:

Hemp License or Registration Number:

Fill in if applicable

EIN #:

Fill in if applicable

How many years are you in business?*:

Please describe what kind of products are you looking for*:

Do you have banking?:

WE DO NOT ACCEPT CASH

Yes No