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Retailer Application Form
BUSINESS INFORMATION
Business Name (
Required
):
*
DBA (if Different) (
Optional
):
Contact Name (
Required
)
*
Email (
Required
):
*
Phone (
Required
):
*
Store Address (
Required
):
*
City (
Required
):
*
State (
Required
):
*
Zipcode (
Required
):
*
LOCATION INFORMATION
How Many Locations Do You Own?
*
How Many Locations Do You Own?
A
1 Location (Independent)
B
2-3 Locations
C
4-5 Locations
D
6+ Locations
CHOOSE YOUR TIER
Untitled checkboxes field
Trial Retailer (25 units @ $12.50/unit = $312.50)
*
Early Retailer (50 units @ $11.50/unit = $575.00)
Launch Partner (100 units @ $9.99/unit = $999.00)
Payment preference:
Untitled checkboxes field
50% deposit now, balance Net 15
*
50% deposit now, balance Net 30
Pay in full (priority fulfillment)
ADDITIONAL INFORMATION
How did you hear about CloudTrack?
*
How did you hear about CloudTrack?
A
Email outreach
B
Phone call
C
Referral
D
Social media
E
Industry event
Are you ready to order now or exploring options?
*
Are you ready to order now or exploring options?
A
Ready to order immediately
B
Need more information first
C
Planning to order
Special requests or questions:
*
I agree to CloudTrack's Retailer Terms and Conditions
*
I agree to CloudTrack's Retailer Terms and Conditions
✅
Submit
