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New Account Form

Email Address

State

First Name

Last Name

Company Name

Website

Telephone

Cell Phone

Business Type

How did you hear about us?

The address below must match the address on your tobacco license as required by law.

I understand

Address Line 1

Address Line 2

City

State

Zip Code

Country

FEIN Number

If you do not have an FEIN number, you may submit your Social Security # and a W-9 in the form of a .pdf, .jpg or .png.

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Business Tax Certificate Number

Please upload your business tax certificate in .pdf, .jpg or .png format.

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Business License Number

Please upload your business license in .pdf, .jpg or .png format.

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Business Tax Certificate Expiration Date

Business License Expiration Date

Excise Tax License Number

Please upload your Excise Tax License Number in .pdf, .jpg or .png format.

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Resale Certificate Number

Please upload your Resale Certifcate in .pdf, .jpg or .png format.

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Resale Certificate Expiration Date

Business Certificate Number

Please upload your business certifcate in .pdf, .jpg or .png format.

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Business Certificate Expiration Date

Tax ID Number

Please upload your Tax ID in .pdf, .jpg or .png format.

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License Certificate Number

Please upload your License Certificate in .pdf, .jpg or .png format.

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License Certificate Expiration Date

Retail Permit Number

Please upload your Retail Permit in .pdf, .jpg or .png format.

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Retail Permit Expiration Date

City License Number

Please upload your City License in .pdf, .jpg or .png format.

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City License Expiration Date

Sales Tax License Number

Please upload your Sales Tax License in .pdf, .jpg or .png format.

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Sales Tax License Expiration Date

Nicotine License Number

Please upload your Nicotine License in .pdf, .jpg or .png format.

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Nicotine License Expiration Date

Tax License Number

Please upload your Tax License in .pdf, .jpg or .png format.

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Tax License Expiration Date

Tax Certificate Number

Please upload your Tax Certificate in .pdf, .jpg or .png format.

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Tobacco Permit Number

Please upload your Tobacco Permit in .pdf, .jpg or .png format.

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Tobacco Permit Expiration Date

Other Tobacco Products Dealer's License #

Please upload your Other Tobacco Products Dealer's License in .pdf, .jpg or .png format.

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Other Tobacco Products Dealer's License Expiration Date

Registration and Licenses Location #

Please upload your Registration and Licenses in .pdf, .jpg or .png format.

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Sales License Number

Please upload your Sales License in .pdf, .jpg or .png format.

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Sales Tax Sales Account Number

Please upload your Sales Tax Sales Account in .pdf, .jpg or .png format.

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Sales Tax Permit Number

Please upload your Sales Tax Permit in .pdf, .jpg or .png format.

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Sales Tax Certificate Number

Please upload your Sales Tax Certificate in .pdf, .jpg or .png format.

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Sales Tax Certificate Number

Please upload your Sales Tax Certificate in .pdf, .jpg or .png format.

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Sales Tax Certificate Expiration Date

Merchant Certificate Number

Please upload your Merchant Certificate in .pdf, .jpg or .png format.

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Tobacco Sales Certificate Number

Please upload your Tobacco Sales Certificate in .pdf, .jpg or .png format.

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Tobacco Sales Certificate Expiration Date

Sales Tax Permit Number

Please upload your Sales Tax Permit in .pdf, .jpg or .png format.

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Sales Tax Permit Expiration Date

Please upload your Certificate of Exemption in .pdf, .jpg or .png format.

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Retail License Number

Please upload your Retail License in .pdf, .jpg or .png format.

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Retail License Expiration Date

Cigarette/Electronic Dealer's License Number

Please upload your Cigarette/Electronic Dealer's License in .pdf, .jpg or .png format.

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Cigarette/Electronic Dealer's License Expiration Date

Sales and Use Tax Certificate Number

Please upload your Sales and Use Tax Certificate in .pdf, .jpg or .png format.

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Sales and Use Tax Certificate Expiration Date

License for Sale of Electronic Nicotine Delivery Systems

Please upload your License for Sale of Electronic Nicotine Delivery Systems in .pdf, .jpg or .png format.

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Resale Certificate Number

Please upload your Resale Certificate in .pdf, .jpg or .png format.

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Certificate of Authority Number

Please upload your Certificate of Authority in .pdf, .jpg or .png format.

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Retail Certificate/Dealer Number

Please upload your Retail Certificate/Dealer in .pdf, .jpg or .png format.

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Retail Certificate/Dealer Expiration Date

Cigarette License Number

Please upload your Cigarette License in .pdf, .jpg or .png format.

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Vendor's License Number

Please upload your Vendor's License in .pdf, .jpg or .png format.

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Please upload your Sales and Use Tax Blanket Exemption Certificate in .pdf, .jpg or .png format.

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Sales and Use Tax Number

Please upload your Sales and Use Tax in .pdf, .jpg or .png format.

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Sales and Use Tax Permit Number

Please upload your Sales and Use Tax Permit in .pdf, .jpg or .png format.

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Tobacco License Number

Please upload your Tobacco License in .pdf, .jpg or .png format.

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Seller's Permit Number

Please upload your Seller's Permit in .pdf, .jpg or .png format.

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Please upload your Form ST-101 in .pdf, .jpg or .png format.

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Retailer/Wholesale License

Please upload your License in .pdf, .jpg or .png format.

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Retailer/Wholesale License Expiration Date

Tobacco License Expiration Date

Tobacco License Type

Additional Note

I have read and agree to the Terms and Conditions and Privacy Policy

PACT Act Document Requirements

PACT Act compliance documents vary depending on your state. Select your state from the list below – if you are not familiar with these documents, please see the provided samples, though yours may vary slightly. In addition to uploading your documents, you must also enter those numbers unique to your business on the license or certificate in the field provided. If you are unable to locate ALL required documents as listed for your state, please contact your Jewel Distribution sales rep or send us an email to admin@jeweldistro.com.

Incomplete submissions will be considered invalid and your business will not be included on the application.

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MY ACCOUNT

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PACT Act Document Requirements

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