Become a Grocery Retailer PhoneThis field is for validation purposes and should be left unchanged.Business + OwnershipLegal Name of Business*Business Open Date* MM slash DD slash YYYY Store Name*Number of Locations*Owner's Name* First Last Store Size (sq. ft)*Contact Name (if different) First Last Business License #*Contact Phone*PST/HST/QST Exemption #Contact Email* Company Composition*Sole ProprietorshipCorporationPartnershipLLCMultiple AccountsWebsite* Accounting Contact InformationAccount Contact Information Accounting Contact Information is the same as Main Contact Information Accounting Contact Name* First Last Company Website Accounting Contact Phone*Company Fax #Accounting Contact Email* Purchasing Contact InformationPurchasing Contact Information Purchasing Contact Information is the same as Main Contact Information Purchasing Contact Name* First Last Purchasing Contact Phone*Purchasing Contact Email* Store AddressAttention To - Name* First Last Email* Address* Street Address Address Line 2 City Province Postal Code Phone*Mailing AddressMailing Address Information Mailing Address Information is the same as the Store Address Attention To - Name* First Last Email* Address* Street Address Address Line 2 City Province Postal Code Phone*Shipping AddressShipping Address Information Shipping Address Information is the same as the Store Address Attention To - Name* First Last Email* Address* Street Address Address Line 2 City Province Postal Code Phone*Type of Business (please check relevant boxes)Type of Business Natural Food Retailer Natural Health Products Retailer Independent Grocery Retailer On-Line Retailer Restaurant, Café, Bakery, Deli, Juice Bar Type of Business Continued Manufacturer Food Service, Commissary, Catering Yoga Studio, Bike Shop, Spa / Health Club Speciality / Gourmet Food, Gift Shop Buying Clubs Other Categories of Interest (please check relevant boxes)Categories of Interest Grocery Chill / Fresh Frozen Bulk Foodservice Categories of Interest Continued Sport Nutrition Household Laundry + Cleaning Household Paper Products Baby / Kids Pet Select Regional Distribution Area (please check relevant box)Regional Distribution Area* Purity Life Grocery – Mississauga, ON Purity Life Grocery – Burnaby, BC Purity Life Grocery – Victoria, BC National - All Facilities Contact ConsentPromotional Information Yes, please email monthly catalogue updates and promotional information General Business Communication Yes, please contact us as needed with general business communication
