Customer Menu

Request A Wholesale Account

Please complete and submit the form below to request a customer account with Vermont Roots. Unless otherwise indicated, all fields are required.

General Information

Company

First Name

Last Name

E-mail

Phone

Federal EIN

Type of Store

Billing Address

Street 1

Street 2 (Optional)

City

State

Zip Code

Shipping/Delivery Address (If different from billing address)

Street 1

Street 2

City

State

Zip Code

How did you hear about us?

Questions or Comments (Optional)