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Retailer Application
Retailer Application
Sorry, we are in the process of finishing up the retailer enrollment process.
If you would like to be notified when it is available, please email us at
info@apostatecigars.com
.
testuser
Apostate Cigars
Please complete this form.
All fields required unless indicated.
Primary Store Information
Store Name
This field is required.
x
This field is not in a valid format.
x
Store Phone
This field is required.
x
Enter a valid phone number.
x
Store Email
This field is required.
x
Enter a valid email address.
x
Primary Contact
Primary First Name
This field is required.
x
This field is not in a valid format.
x
Primary Last Name
This field is required.
x
This field is not in a valid format.
x
Primary Phone
This field is required.
x
Enter a valid phone number.
x
Primary Email
This field is required.
x
Enter a valid email address.
x
All emails from ApostateCigars.com will be sent to the Primary Email address.
Primary Store Address
Store Street 1
This field is required.
x
This field is not in a valid format.
x
Store Street 2
optional
Store City
This field is required.
x
This field is not in a valid format.
x
Store State
This field is required.
x
This field is not in a valid format.
x
Store Zip
This field is required.
x
Enter a valid zip code.
x
Primary Ship To Address
Use other address…
Use the Store Address
Use the Billto Address
Shipto Street 1
This field is required.
x
This field is not in a valid format.
x
Shipto Street 2
optional
Shipto City
This field is required.
x
This field is not in a valid format.
x
Shipto State
This field is required.
x
This field is not in a valid format.
x
Shipto Zip
This field is required.
x
Enter a valid zip code.
x
Primary Bill To Address
Use other address…
Use the Shipto Address
Use the Store Address
Billto Street 1
This field is required.
x
This field is not in a valid format.
x
Billto Street 2
optional
Billto City
This field is required.
x
This field is not in a valid format.
x
Billto State
This field is required.
x
This field is not in a valid format.
x
Billto Zip
This field is required.
x
Enter a valid zip code.
x
Username/Password
Username
This field is required.
x
Use only letters, numbers, and _ . - @
x
Must be 6 characters or more.
x
Password
This field is required.
x
Letters, numbers, and _ . - @ ! # $ % & only
x
Must be 12 characters or more.
x
Verify Password
This field is required.
x
Letters, numbers, and _ . - @ ! # $ % & only
x
Must be 12 characters or more.
x
Passwords do not match.
x
Please note that passwords must be at least 12 characters in length using any combination of letters and numbers in addition to the following accepted characters: # @ ! $ % ^ & *.
You certify that the information you are submitting is true and accurate to the best of your understanding. Any incorrect information may be cause for termination of your ability to distribute our products either temporarily or permanently. This application does not grant nor guarantee the formation of a distributor relationship between you and Apostate Cigars.
By submitting this form you are signing this request for distributorship and this signature binds all distributors to the rules and policies of Apostate Cigars if such a relationship is approved by Apostate Cigars.
Please allow 1-2 weeks for this application to be reviewed. You will be notified of your acceptance or rejection by phone or email or if we have further information that is needed to process your request.
Accept Terms
