Client Information

Vapor Sales Representative

Billing Details

Company*

Billing City *

Billing Address *

Billing Postal Code *

Billing State/Province *

Billing Country *

Phone *

Fax

Email *

Re-enter Email

Ship To Company

Ship To Address

Ship To City

Ship To State/Province

Ship To Postal Code

Ship To Country

Ship To Contact

Ship To Phone

Ship To Fax

Ship To Email

FedEx Account

Tax ID

*Please provide a copy of current years Resale Certificate and Retail License for the company named above.