Lucy Wholesale Application

Lucy Wholesale Application
Business Name*
Contact Name*

First NameLast Name
Contact Number*

Area CodePhone Number
E-mail*
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about us

Facebook AdInstagram AdTrade PublicationOther
Type of Business*

RetailDistributorE-CommerceOther
Which Lucy products are you interested in stocking?*

Chew & Park Nicotine GumLozengesKapsel Nicotine PouchesSlim Nicotine PouchesAll
Number of Units Desired
100 Packs of Mint Gum, 5 Rolls of Kapsel Pouches
Preferred Payment Method

Credit CardACH
Message*
Should be Empty: