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2. First Name*
3. Last Name*
5. Contact Phone Number*
6. Contact Email*
8. Individual Responsible for Sales (Name)
10. Retail Sales Address

    If more than one location, please use the upload feature below to submit all locations.

12. City
13. State
14. Zip
16. Multiple Locations Upload Portal
18. Submitted Application to OSFM

    1. OSFM Application Submitted
20. You will be redirected to the payment page after completing this form.
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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

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