Customer Registration

* Required Fields
Contact Information
Business Name:*    
First Name:*    
Last Name:*    
Title/Position:*    
Phone:*      
Cell:    
Fax:    
Email:*      
Billing Information   
Address 1:*    
Address 2:
City:*
      Province:*        Zip:*      
Shipping Information    Copy Billing Information   
Address 1:*      
Address 2:
City:*  
      Province:*        Zip:*      
Business Information
Type of Business:*   
Legal Business Name:*    
Name of Legal Business Owner:*    
Tobacco Retail License #:*    
Expiration Date:*    
Federal Tax ID #:*    
How Long in Business:*    


Questions/Comments ***DO NOT ENTER CREDIT CARD INFORMATION***

Kretek International does not offer the sale of tobacco products to persons under the legal smoking age nor do we offer product to non-licensed individuals. By submitting this form you certify that you are 21 years of age or older and are a licensed retailer.



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