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Company Information:
Company Name:
*
First Name
*
Last Name
*
Title:
*
Owner
Manager
Buyer
Assistant Buyer
Other
Mailing Address
*
City
*
State
*
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
DC - Washington DC
Zip Code
*
Email Address
*
Phone Number:
*
Fax Number:
EIN Number/Resale Permit Number:
Password for Login:
*
URL/Website:
Do you sell products on your website?
Yes
No
Type of Business:
*
Storefront
Website
Person-to-Person
Type of Store:
🛈
Organic Products
Maternity
Apparel
Recreation
Children's Store
Baby Store
Grocery Store
Healthcare
Lactation Consultant
Midwife/Doula
Primarily Dermatology
Chiropractor
Other
Company Information:
Notes:
Please upload a copy of your resale permit/business license, if available:
🛈
Please note: Episencial, LLC. reserves the right to work only with retailers who we deem a good fit, and who are aligned with our
core values
. This is solely at Episencial’s discretion – resell of all Episencial products is limited to approved retail partners.
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