Corporate Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

When did your company begin manufacturing vape products? *

MM

DD

YYYY

Do you sell direct to consumers? *

Yes

No

Does your branding / packaging include IP theft, marketing that would appeal to children, or anything along those lines? *

Yes

No

Do you monitor and uphold your MAP / MSRP? *

Yes

No

Do you offer multiple store / chain discounts? *

Yes

No

Is your product currently sold on "ejuiceconnect" or any similar "wholesale to the public" websites? *

Yes

No

Are you currently active in local, state, or federal vaping advocacy groups? *

Yes

No

Do you provide point of purchase marketing material for your brick and mortar retail accounts? *

Yes

No

Do you provide samples / testers with every order? *

Yes

No

Were your products manufactured prior to August 8th, 2016? *

Yes

No

Do you provide master case bottle discounts? *

Yes

No

Contact Name *

First Name

Last Name

Phone Number *

Country

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