Direct Account Registration

Direct Account Application

Please provide all required details for your direct buying requests.

Store Name:*
Contact:*
Address:*
Phone Number:*
Email Address:*
Password:*
Confirm Password:*
Tax ID or SSN (Form W9):*
Do you have a Tobacco License?*
Yes No
Current Tobacco License Number:*
Current Tobacco License State: *
Current Sales & Use ID Number:*
Current Sales & Use State: *