SUBMISSION FORM

Account Name *

Buyer Name *

Phone *

Email Address *

Brand Name *

Billing Address *

Shipping Address *

Website Address *

Competitive Brands Carried *

What makes you a good fit to be a retailer for this brand? *

Picture of inside of store: *

Click or drag a file to this area to upload.

Picture of outside of store: *

Click or drag a file to this area to upload.

Projected store volume for this brand *

Additional Comments: *

Website