New Retailer Form

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Store Name must match the name on the Resale Permit

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Please list the first and last names of all the personnel who are authorized to place orders on behalf of your store below.

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Use the e-mail address that you want to be used with communication from us.

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If different from the address on the Resale Permit please explain the discrepancy under comments.

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Choose All That Apply

If "Other", please specify under comments what this is regarding to.

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