Retailer Request Form

Retailer Name *
Corporate name (if applicable)
Address *
City *
State *	zip *
Phone *
Fax
Email *
Contact Person *
Title
Number of stores
States store located
Candy & Tobacco wholesaler name *
Novelty Distributor name
Currently carrying DMD products?	yes no
If yes, from
Other brands retailer is selling
Does retailer understand the obligations for List 1 Chemicals (2 is Rule - Report Suspicious Activity)	yes no
What prompted retailer to contact DMD?
Comments