Request a ResQ Vape Bin for Your Shop! Your Name * First Name Last Name Your Email * (Required – so we can follow up) Your Phone (###) ### #### Vape Shop Name * Vape Shop Address (Required – at least city & state) Address 1 Address 2 City State/Province Zip/Postal Code Country Vape Shop Phone Number (###) ### #### Vape Shop Website or Social Media Link (Optional – helps us contact them) Why Do You Think This Shop Needs a ResQ Bin? Do You Work at This Vape Shop? Yes No
