Stockist Application Form

Interested in becoming a Burgh stockist? First, let’s find out a little more about your store.

Just fill out the form below and our team will be in touch to get things rolling.

Name(Required)

First Last

Business Name(Required)

Position(Required)

Email(Required)

Phone Number(Required)

Business Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Address (If different to the above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Registration Number (e.g. ABN, EIN, CRN, USCC)(Required)

Tax/VAT ID(Required)

Business Website(Required)

Facebook(Required)

Instagram(Required)

Store Type(Required)

Do you sell product online? If so, is this on your store website and/or third-party platforms?(Required)

What other brands do you stock?(Required)

Years in operation(Required)

How did you hear about Burgh?(Required)

Any additional information to support your application

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