Harris Customer Establishment Form
Email address *
Contact Name *
Your answer
Business Name *
Your answer
"Doing Business As" Retail Name *
Your answer
Retail Business Full Address *
Your answer
Retail Business Phone Number *
Your answer
Permit Type(s) *
Check all that apply.
Required
Permit Number(s) & Expiration Date(s)
List all that apply.
Your answer
Retail Business Type
(Per Permit)
Chain Status *
Chain Name & Location Number
(If Applicable)
Your answer
Payment Type *
Product Type *
Check all that apply.
Required
A copy of your responses will be emailed to the address you provided.
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