Reseller Application Name * First Last Referred By Enter name or who referred you to Hempfield Labs Company Title Email Address * Street * City * State * — Select — Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 District of Columbia Zip Code * Additional Information Area of Interest * Regional Distributor Non-Stocking Reseller Stocking Reseller Check all that apply Business Website (if any) Enter URL using http:// as a prefix to the website. For example https://hempfieldlabs.com How did you hear about us? * — Select — Facebook LinkedIn Instagram Twitter Customer Referral Review Other Other Description Forecasted Monthly Volume * — Select — Small (under $1,000 monthly) Standard ($1,000-$10,000 monthly) Large (over $10,000 monthly) Comments
