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New Distribtor Rgistration


Contact Information
Business Name*  
First Name*  
Last Name*  
Title/Position*  
Phone*  
Alternate Phone
Fax
Email*    
Billing Information
Address 1*  
Address 2
City*   State*
v
  		Zip*  
Shipping Information
Address 1*  
Address 2
City*   State*
v
  		Zip*  
Business Information
Type of Business*
Legal Business Name*  
Name of Legal Businss Owner
Tobacco Retail License #
Expiration Date
Federal Tax ID #*  
How long in Business*  

Questions/Comments ***DO NOT ENTER CREDIT CARD INFORMATION***

Kretek International does not offer the sale of tobacco products to persons under the legal smoking age nor do we offer product to non-licensed individuals. By submitting this form you certify that you are 21 years of age or older and are a licensed retailer.

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