Medic Grow Dealer Application Company name * DBA or AKA Company Website Date business commenced * Type of business * Sole proprietorshipLLCPartnershipCorporationOther Federal Tax ID (EIN) * State Sale Tax Certificate No. * Company Address *Street, City, State ZIP Code CONTACT INFORMATION Username * Password * Primary Contact * Position/Title * Phone * Fax Email Address * WHO ARE YOUR TYPICAL CUSTOMERS? EXPLAIN * DO YOU SELL OTHER BRANDS OF HORTICULTURAL GROW LIGHTS? IF SO, WHICH BRANDS? * WHY DO YOU WANT TO SELL MEDIC GROW LIGHTS? * DO YOU NEED MEDIC GROW SAMPLE EQUIPMENT? IF SO, EXPLAIN * VERIFY AND SUBMIT Certification * I certify that the above facts are true to the best of my knowledge and belief. I understand that making false statements on this application will be grounds for rejection or termination from the Medic Grow Dealer Program. Type Name * Title * Date * Please attach a copy of your State Sales Tax Certificate or "Seller’s Permit" File name: File size: Validate Email
