New Customer Registration Form

101 Distributors Mega Summer Trade show - Customer Registration Form

Contact Information

Please fill out your contact inforamtion

First Name

Last Name

Phone/Mobile

Business Information

Please enter your business infomration

Legal Business Name

DBA Name

Prefered Sales Representative Name

Primary Business

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

County

Document Required

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Business License Number

Business License

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OTP/Vape/Tobacco License Number

OTP/Vape/Tobacco License

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Federal EIN Document Number

Federal EIN Document (FEIN)

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Hemp License Number

Hemp License

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Driving License Number

Driving License

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Bank Name

Void Check

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I have read,understand and agree to be bound by the above

Addendum to ACH Authorization Agreement

Purchaser agrees that in the event of a defualt or breach of this agreemnet by Purchaser,to include failure to pay invoice(s)in full,proper venue for any claim by 101 Disibutors LLC against Purchaser shall reside in the Circuit Court of leon Country,Georgia.This agreements shall be governed by the law of the State of Georgia.

Purchaser agrees that shall personally guarantee the payment of any sums due and owing by Purchaser by 101 Disibutors LLC