THE CITY FARM WHOLESALE REQUEST FORM

To request a wholesale account, please fill out the form below.
We look forward to working with you.

General Information
Name*
First Last
Email*
Phone
Password*
Enter Password Confirm Password
Company Name*
Business Type*
Other*
Tax ID*
Years in Business*
How did you hear about us*
Other*
Billing Information
First Name*
Last Name*
Phone*
Company*
Billing Address*
Street Address Address Line 2 City or APO / AFO State / Province / Region ZIP / Postal Code Country
Shipping Information
- Use my billing address as my shipping address
Full Name*
Phone*
Company*
Address
Street Address Address Line 2 City or APO / AFO State / Province / Region ZIP / Postal Code Country
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