All fields are required. Please fill them all out to the best of your ability. "N/A" is an acceptable response ONLY to those questions that are not applicable to your business. Incomplete applications will only delay the decision process.

Contact Person for the Application

Retailer Information

Sales Information


Other Info

By submitting this form, you certify that the above information is true and accurate in all respects and that MLBP may rely on such information to determine approved retailer status for the sale of MLBP-licensed products.