Licensed Entity Name*
Brand Name (or DBA)*
Company Type* DistributorManufacturerOther
License Expiration Date*
Distribution License PDF* Please upload a copy of your state cannabis license.
Distributor Seller's Permit*
Cultivation/Manufacturing License PDF*If possible, please provide a copy of the manufacturer or cultivator state cannabis license.
Distributor Contact First Name*
Distributor Contact Last Name*
Distributor Contact Phone Number*
Distributor Contact Email*
Brand Contact First Name*
Brand Contact Last Name*
Brand Contact Phone Number*
Brand Contact Email Address*
Expected Number of SKUs*
Distribution Delivery Restrictions/Preferences* Please list any time, day or date restrictions and/or preferences for delivering products.
Notes Please leave any notes that might be useful for our team.
If you are interested in more information on becoming a sponsor, please email: email@example.com