First Name *

Last Name *

Company *

Street Address *

Address 2

State / County *

Town / City *

Postcode / Zip *

Phone *

Type of Business
*

Select…
Retailer
Wholesaler
Distributor

Website Address

Authorized Representative(s) For Pick Up
To comply with the Pact Act, we’re asking you to fill out the section below. Please ensure all names provided for each field on the form are spelled correctly and match precisely what is shown on government-issued identification or license. Only those listed below will be allowed to pick up products from your local USPS location.

Authorized Representative(s) For Pick Up • Owner
*


First and Last Name

Authorized Representative(s) For Pick Up • Employee 1



While additional authorized representatives are not required, we encourage you include some of your employees as additional authorized representatives for pickup since only those listed in this form are allowed to pick up products on your company

Authorized Representative(s) For Pick Up • Employee 2



While additional authorized representatives are not required, we encourage you include some of your employees as additional authorized representatives for pickup since only those listed in this form are allowed to pick up products on your company

FEIN#

Upload Your FEIN

Upload Your Tobacco License (If Applicable)

Upload Additional Permits or Licenses (If Applicable)

Upload A Photo Of Any Other Permits or Licenses Required By Your State Or Local Government (if applicable)

Security *