New Reseller Customer Questionnaire

Company Name *

Mailing Address *

Office Phone Number *

Primary Billing Contact Name *

Primary Billing Contact Phone Number *

Primary Billing Contact Email *

Shipping Address 1 *

Do you have multiple shipping addresses? *

If Yes, please list the multiple shipping addresses in this text box below.

Are you sales tax exempt? *

If yes, please provide a copy of your sales tax exemption form before you complete this questionnaire to [email protected] in order to avoid being charged sales tax.

Does your company have a pesticide dealer, applicator, or other chemical license from your state? *

If yes, please upload a copy of your license or email a copy of your license to [email protected]

Click on the arrow and upload the copy of your license.

Please provide your company’s DUNS #

If your company does not have a DUNS #, please click the blue hyperlink below and follow the instructions to procure a free DUNS # and then complete the fillable line above.

For DUNS # Directions Click Me...

I confirm all the information above is accurate. *

yes