Enriching Materials For Body, Mind and Spirit

New Customer Form

To set up an account with Dempsey Distributing, please complete this form and submit it to us.
We do not take any payments online. All new accounts must prepay before shipment.

Store Name:
Address
Street:
Suite Number:  
City:
Province:
Postal Code:
Business
Type of Business:
Business opening date (mm/dd/yyyy):
Website Address: (Enter NONE if none yet)
GST / EIN / First Nations Exemption Number:
Business Licence Number:  
Store Phone Number (###-###-####):
Email address of Buyer:
Email address for A/P Statements:
Owner's Name:
Owner's Cell Number (###-###-####):
Preferred password for Dempsey website (6 - 8 chars):
(if not supplied, we will automatically generate one for you)
 
Questions or Comments: