? Dempsey Distributing
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
Store Address
Street:
Suite Number:  
City:
Province:
Postal Code:
Shipping Address
Street:
Suite Number:  
City:
Province:
Postal Code:
Business
Type of Business:
Business opening date (mm/dd/yyyy):
Website or Facebook Address: (Enter NONE if none yet)
GST / EIN / First Nations Exemption Number:
Business Licence Number:  
Store Phone Number (###-###-####):
Name of Buyer:
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)
 
Tell us a little bit about your business:    
 
 

Applications are reviewed by our Customer Service Department and set up within 8 business hours. You will be notified with your login credentials at that time.

Please do not submit more than once.

 

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