2024 Grassroots Retail Membership Initial Inquiry Form

Grassroots Membership Initial Inquiry Form

Thank you for your interest in Grassroots membership. Please complete this inquiry form as the first step in our application process. If you meet the minimum qualifications, our team will contact you with the next steps.

1. Please provide your basic contact and store information. *This question is required.

First Name

Last Name

Title

Do you currently hold an ownership stake in the company? *This question is required.

Company Name

Street Address

City

State

Zip

Country

Email Address

Primary Phone Number

URL to primary company website