Wholesaler new application

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»	Billing address
	Address:
	Town/City:
	State/County:	ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS ARMY POST OFFICE CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLEET POST OFFICE FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARSHALL ISLANDS MARYLAND MASSACHUSETTS MICHIGAN MICRONESIA MINNESOTA MISSISSIPPI MISSOURI MONTANA N MARIANA ISLANDS NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS TRUST TERRITORIES UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
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	Contact Number:
»	Shipping address  ( same as the billing address)
	Address:
	Town/City:
	State/County:	ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS ARMY POST OFFICE CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLEET POST OFFICE FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARSHALL ISLANDS MARYLAND MASSACHUSETTS MICHIGAN MICRONESIA MINNESOTA MISSISSIPPI MISSOURI MONTANA N MARIANA ISLANDS NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS TRUST TERRITORIES UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
	Post/Zip code:
	Country:	United States
»	For us to access your application we ask that you complete all the questions below
	What will be your method of re-sale and who will be your intended customer base? N.B Web Based re-selling will not be supported by our Company at this stage.
	What is your current experience of vaping and what kind of product knowledge do you have?
	What kind of experience do you currently have of re-selling, retail and marketing in general?
	What are your target sales for the first year of selling our products and do you have any figure projections for the future of your intended business with us?
	What kind of support would you require or request from our Company?
	Enter the code you see in this box:
	I have read the terms and conditions and in principle agree with them.