Company Name *
DBA (Doing Business As) *
First + Last Name *
Email *
Phone Number *
Business Street Address *
Business City *
Business State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Type of Business * Boardsports Fitness Studio Golf Lifestyle/Fashion Military Outdoor Resort Running Sporting Goods Other
How many years have you been in business? * <1 Year 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years >10 Years
How many locations does your company have in total? * 1 2 3 4 5 6 7 8 9 10+
How many locations are you looking to open with Coolibar? * 1 2 3 4 5 6 7 8 9 10+
What is the square footage of your retail space? *
What are the top 3 brands that would sit adjacent to Coolibar in your store *
1st Year Projected Wholesale Bookings * $2500 - $5000 $5,000 - $10,000 $10,000 - $15,000 $15,000 - $20,000 $20,000 - $25,000 $25,000+
2nd Year Projected Wholesale Bookings * $2500 - $5000 $5,000 - $10,000 $10,000 - $15,000 $15,000 - $20,000 $20,000 - $25,000 $25,000+
3rd Year Projected Wholesale Bookings * $2500 - $5000 $5,000 - $10,000 $10,000 - $15,000 $15,000 - $20,000 $20,000 - $25,000 $25,000+
Account Request Type * New Wholesale Account
Please tell us more about your retail store *
