Account Application

Actus Wholesale Account Application Form

If you are interested in stocking CANARY, please 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) *

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? *

Comment *

Submit