Wholesale Partner Application

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Business Information

Business Name: _________________________________________

DBA (If Applicable): ______________________________________

Business Type:

☐ Retail Store

☐ Online Retailer

☐ Distributor

☐ Janitorial Supply

☐ Health & Wellness Retailer

☐ Commercial Cleaning Company

☐ Other: ______________________

Years in Business: __________

Federal Tax ID (EIN): ______________________________

Website: ___________________________________________

Primary Contact

Name: _____________________________________________

Title: ______________________________________________

Phone: ____________________________________________

Email: _____________________________________________

Billing Information

Billing Address:

City: __________________ State: ______ Zip: __________

Accounts Payable Contact:

Accounts Payable Email:

Shipping Information

Shipping Address:

City: __________________ State: ______ Zip: __________

Receiving Contact:

Receiving Phone:

Business Profile

Please tell us about your business:

How do you plan to market or sell Culleoka Company products?

Estimated First Order Volume:

☐ $250–$1,100

☐ $1,101–$1,800

☐ $1,801+

Wholesale Program Acknowledgement

I certify that all information provided in this application is accurate and complete.

I understand that approval into the Culleoka Company Wholesale Partner Program is subject to review and acceptance by Culleoka Company.

Applicant Name:

Title:

Signature:

Date:

Please return completed applications to:

joeljohnson@culleokacompany.com

855-777-6246

Culleoka Company LLC
P.O. Box 204
Culleoka, TN 38451