Customer Application

You must have an account with us and be over 21 to purchase nicotine products

BUSINESS INFORMATION

Business Name *

DBA

Federal Tax ID/TIN *

Sales Tax ID *

Website

Business Phone *

Mobile Phone *

Email *

Street Address *

City *

State *

Postal/ZIP Code *

Ownership Type *

Date Established *

Type of Business *

Type of Business ("Other" Selected) *

AUTHORIZED PURCHASER

Owner/Principal *

Title *

Upload a Photo of your Business License / Reseller's Permit or Sales and Tax Exemption Certificate. *

Upload a photo of your Drivers License or ID *

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