Wholesale Account Form
Legal Business Entity Name*
Fictitious Business Name/DBA
License
License Type(s)*
Distributor
Distributor Transport Only
Microbusiness
Processor
Manufacturer - Type 7 (Volatile)
Manufacturer - Type 6 (Non-Volatile)
Manufacturer - Type N (Infusions)
Manufacturer - Type 7P (Packaging)
Retailer
Retailer (Non-Storefront)
License Number(s)*
Premises Address*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
BCC, CDPH, or CDFA Licenses*
No File Chosen
Authorized Purchaser
Purchaser Name*
Purchaser Phone*
Purchaser Email *
Additional Purchaser(s)
Please include name, phone and email of any team members authorized to evaluate products, negotiate rates, and execute purchase agreements.
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Product Needs
When would you like to begin ordering?*
ASAP
7 days
30 days
60-90 days
Other:
Are you interested in custom cultivation?
Yes
Not right now
Tell me more
Other:
What product(s) are you interested in? Choose all that apply.*
Trimmed flower (1/2"-2" in size)
Untrimmed flower (Mixed sizes)
Trimmed flower (Less that 1/2" in size)
Untrimmed flower (Less than 1/2" in size)
Biomass (Mix of flower/leaves)
Trim/Leaves
Vape Carts
Concentrates
Edibles
Tinctures
Topicals
Prerolls
Other:
How did you hear about us?
Friend/Colleague
Search Engine
Instagram
Trade Show
Other:
Requested Terms*
COD
Net 30
Net 45
Net 60-90 (Extended/Trade Credit)
Other:
Additional Comments
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