Registration Type: {radio-2}

First Name: {name-1-first-name}

First Name: {name-1-last-name}

Username: {text-1}

Password: ••••••

Company Name: {text-2}

Title/Position: {text-5}

Website: {url-1}

Tax ID Number: {text-4}

Email: {email-1}

Phone: {phone-1}

Type of Retail Store: {radio-3}

Please Specify Other: {text-9}

Number of Locations: {number-1}

# of Retail Accounts You Service: {number-2}

Distribution Region (States/Countries): {textarea-1}

Estimated Monthly Purchase Volume: {radio-4}

Select your Sales Rep: {select-3}

Resale Certificate / Tax Exemption Certificate: {upload-1}

Driver license: {upload-2}

Agreement & Submission: {consent-1}