Broker Application

Broker: A Sales Representative contracted to represent a TPA Associate Member company and who sells their products to TPA Retail members.

Required Documentation: Brokers must be sponsored by at least one (1) Associate member as part of the application process. Indicate the sponsoring associate member(s) on your application. TPA will verify prior to approving membership. (from TPA)

AFTER SUBMITTING YOUR APPLICATION, YOU WILL BE REDIRECTED TO THE PAYMENT PAGE
NO APPLICATIONS WILL BE PROCESSED WITHOUT FULL REMITTANCE.

First Name *

Last Name *

Company

Email *

Phone *

Address *

City *

State *

Postal Code *

Country *

Website *

Which membership are you applying for?

Industry Partners applying for membership should have established relationships with at least 1 current PCA Associate/Manufacturer member. Provide the name(s) of those companies here. If none is available, provide an explanation.

Sponsoring PCA Associate Members (company names)

1.
2.
3.

No Established Relationship Explanation

How many employees work for your company (including yourself)? *

Social Accounts

Facebook
Instagram
Twitter
LinkedIn
YouTube
Google Business Profile

Were you referred by someone?

Referrer Member name

Items to Upload

Please upload the following items. Your application will not be processed until we have all the requested documentation.

• Your State Tobacco Sales License

• State Issued Retail License

• A picture of the interior of your business

• A picture of the exterior of your business

Upload Requested Documents

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (XXX) XXX-XXXX for assistance. You can reply STOP to unsubscribe at any time.

Captcha

AFTER SUBMITTING YOUR APPLICATION, YOU WILL BE REDIRECTED TO THE PAYMENT PAGE
NO APPLICATIONS WILL BE PROCESSED WITHOUT FULL REMITTANCE.