Business Name (required)

Type of Business
Retail StoreDistributorOnline RetailerConvenience StoreOther

Business Address (required)

City (required)

State
ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP Code (required)

Business Phone Number (required)

Business Email Address (required)

Password (required)

Confirm Password (required)

Primary Contact Name (required)

Title / Role

Contact Phone Number (required)

Contact Email (if different)

Upload Tobacco Retail or Distributor License

Upload Resale Certificate / Sales Tax Permit

Upload Business License or Proof of Registration

Upload Owner or Manager Photo ID (21+)

Estimated Monthly Order Volume
Under $1,000$1,000–$5,000$5,000–$10,000Over $10,000

Preferred Communication Method
EmailPhoneWhatsAppOther

I confirm that I am 21+ and authorized to make purchasing decisions for this business.

I understand all nicotine orders require valid licenses, age verification, and adult signature.