Retailer Application

Store Name *

Company Legal Name *

Address Line 1 *

Address Line 2

City *

Province/State/Region *

Country *

Company Owner Full Name *

Email *

Website

Phone Number *

What year was your company established? *

Store Type *

What market segment do you represent * Baby Gift shop Department store Supermarket Pharmacy Other

How many product lines do you currently sell?

Tell us about your shop *

Is there any additional information you’d like to provide?