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Reseller Registration
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Company Name
Trading Name
CIPC REG No.
Vat No.
Trading Period
Less than 1 Year
1 Year
2 Years
3 Years
4 Years
5 Years
More than 5 Years
Website
Company Address
City
Province
Postal Code
Business Type
Off Site consumption Retail
On Site consumption Retail
On Site consumption retail & restaurant
Open Kiosk
Surname
First Name
Title
Mr
Ms
Mrs
ID/Passport No.
Residential Address
City
Postal Code
Province
Contact Number
Company Tel
Email
Surname
First Name
Title
Mr
Ms
Mrs
ID/Passport No.
Residential Address
City
Postal Code
Province
Contact Number
Company Tel
Email
List Of Products Intended to Sell (Required)
Pre-Rolls (Indoor / Greenhouse / Outdoor)
Concentrates/ Extracts
Animal Range Products
Medical / Traditional Remedies
Hemp Products
Flower (Indoor / Greenhouse / Outdoor)
Food & Beverages
Vapes / Carts
Wellness Products
Personal Care & Cosmetics
Accessories & Merchandise
Other
If Other Is Selected Please Specify
Account Name
Account Number
Bank Name
Account Type
Savings Account
Cheque / Current Account
Business Account
Corporate Account
Trust Account
Joint Account
Branch Code
Acceptance
By accepting, you hereby certify that all information provided is complete, true, and accurate to the best of your knowledge. You acknowledge and agree that any false, misleading, or incomplete information may result in the immediate denial or revocation of your application, and may subject you to civil or criminal liability under applicable laws and regulations.
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