Wholesale Application

Your First Name*:
Your Last Name*:
Your Email*: name@domain.xxx
Your Contact Phone*: nnn-nnn-nnnn
Type of Business: Retail StoreOnline StoreSporting VenueSalon/BeautyOffice/CorporateSchool/UniversityResellerDistributorOther (explain in message area below)
Additional Info or Message:
Business Name*:
Business Address*:
Business Address2:
Business City*:
Business State: AL AlabamaAK AlaskaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFL FloridaGA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaOH OhioOK OklahomaOR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY WyomingXX Other
Business Zip:
Business/Resale License #*:
State Your License is in: AL AlabamaAK AlaskaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFL FloridaGA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaOH OhioOK OklahomaOR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY WyomingXX Other