Are you a current L&R Customer *

First Name *

Last Name *

Company Name *

Phone *

Tax ID *

L&R Customer ID

Billing Address

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Shipping Address

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

What is the email address you want to use as your new eShop Log in? *

Note: This email address will be used as both your eShop username to log in and as the email associated with your account for order confirmations, password resets, identity verification and more.

By checking this box, I consent to receive marketing emails from L&R Distributors. *

If your account is approved, are there any additional users that require access?

A separate login will be created for each email provided.

Are there any additional users that require access?

A separate login will be created for each email provided.

Where would you sell products purchased from L&R Distributors? *

Brick & Mortar
Own Website
Elsewhere Online *Note that our brands prohibit us from selling to customers for resale on 3P marketplaces.

Brick & Mortar Store Address *

Storefront URL *

Where do you sell online? *

What is the anticipated dollar amount in sales you will do monthly? *

Is your business registered in the US? *

Yes
No

Do you have your own warehouse? *

Yes
No

Your business must be registered in the US to open an account.

Please provide the warehouse address. *

Please note that we do not offer international sales at this time.

What are the primary categories you are looking to purchase: *

How did you hear about us: referred by vendor, word of mouth, other? *

We appreciate your interest in purchasing from L&R Distributors and look forward to doing business with you. We require additional information in order to process your application. Please provide the following information:

(Trade references not required if not applying for terms.)

A complete and signed W9. You may download a blank .pdf of the form by clicking this link. *

Choose file or drag here

Supported format: PDF

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A valid resale certificate. If you do not have a valid resale certificate issued by your state, you may download a blank .pdf of the Uniform resale form by clicking this link. *

Choose file or drag here

Supported formats: PDF, JPG, JPEG, PNG, SVG

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A completed New Customer Form. You may download a blank .pdf of the form by clicking this link. *

Choose file or drag here

Supported format: PDF

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Do you have any other documents you would like to include?

Choose file or drag here

Supported formats: JPG, JPEG, PNG, PDF, SVG, DOC, DOCX

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