Retailer Registration

Apply to join the Launch Code Giveaway as a certified Moongrass retailer

Business Information

Business Name *

Store Type *

Store Address *

State *

Primary Contact

Owner / Contact Name *

Email Address *

Phone Number *

Licensing Information

Upload Hemp License *

Click or drag to upload (PDF, JPG, PNG)

License Expiration Date *

Moongrass Customer Status

Do you currently carry Moongrass products? *

Yes

No, but I would like to become a Moongrass retailer

Reimbursement Preferences

Preferred Reimbursement Method *

Credit Toward Future Orders

Cash Reimbursement

Public Store Locator

Would you like your store listed as a participating location on the Moongrass website?

Yes

Required Agreements

I certify that I am authorized to act on behalf of this business.

I agree to honor valid Moongrass-issued promotional coupons.

I understand that reimbursement requests are subject to verification and approval.