Distributor Request Form

Distributor Name *
Address *
City *
State *	zip
Phone *
Fax *
Email *
Contact Person *
Title
No of stores Serviced
List of states serviced
Retail locations serviced (Check all that apply)	Chain C-Stores Drug Stores Grocery Stores Travel Plazas Independent Stores
Do you service any of the following (Check all that apply)	Liquor Shops Video Stores Beauty Shops
Other brands distributor is selling
What prompted distributor to contact DMD?
Has this company been issued any DEA warning letters?	yes no
Comments:

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