RETAILER APPLICATION Retailer Registration Please fill out this form and we will contact you to discuss your application. Retailer Application Date * Business ID (EIN) or Social Security # (SSN) * Which Vireo products are you interested in selling? pH-D Feminine Health Promera Sports Amino Activ Canine Activ SANZ Laundry Detergent SANZ Odor Neutralizer Personal Information Name * Company Name * Email Address * Phone Number * Website/URL * Address * City * State * Select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other State Zip Code * Business Details Proof of Business License * Please select Upload File Now Mail Proof of Business License / Tax ID / Other (pdf, png, jpg, or gif) Drop a file here or click to upload Choose File Maximum upload size: 2.1MB Mail I will mail a copy of my Business License and Tax ID to Vireo Systems, Inc 305 Williams Avenue Madison, TN, 37115 Is your business EDI capable? Yes No How did you hear about Vireo Systems? Tradeshow Referral Amazon Vireo Website Google Search Facebook Instagram OtherOther Check the box below * I have read the Retailer Agreement required for approved retailers. Once we have reviewed and approved your application, we will send you the Retailer Agreement for your signature. If you are human, leave this field blank.