Account Application w terms

Actus Wholesale Account Application Form

If you are interested in stocking CANARY please read Actus's Terms & Conditions and fill out the form below.
If you have further questions our accounts team is available at agent@actus-usa.com or 212-575-8081.

* Indicates required field

Store/Company Name *

Name *

First

Last

Email *

Phone Number *

Website *

State Resale Number (required for US retailers) *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Where do you conduct business? *

Physical Retail Location(s) E-commerce Website Owned by my Business Third Party Reseller (e.g. Amazon, eBay, Sears, Walmart, etc.) Distributor

How many locations do you have? *

Tell us a little about your business. *

How did you hear about us? *

Submit