{"id":31588,"date":"2026-04-23T06:28:50","date_gmt":"2026-04-23T06:28:50","guid":{"rendered":"https:\/\/ampgarden.com\/?page_id=31588"},"modified":"2026-04-23T06:28:50","modified_gmt":"2026-04-23T06:28:50","slug":"wholesale-dealer-account-application","status":"publish","type":"page","link":"https:\/\/ampgarden.com\/?page_id=31588","title":{"rendered":"Wholesale Dealer Account Application"},"content":{"rendered":"\t<section class=\"section\" id=\"section_2803000480\" >\n\t\t<div class=\"section-bg fill\"  >\n\t\t\t        \n\t\t\t            \n\t\t\t\t\t\t\n\n\t\t<\/div>\n\n\t\t\n\n\t\t<div class=\"section-content relative\">\n\t\t\t\n<div class=\"row align-center\"  id=\"row-1481343442\">\n\n\t<div id=\"col-1636257467\" class=\"col medium-9 small-12 large-9\"  >\n\t\t\t\t<div class=\"col-inner box-shadow-2\" style=\"background-color:rgb(255, 255, 255);\" >\n\t\t\t\n\t\t\t\n<div class='fluentform ff-default fluentform_wrapper_60004 ffs_default_wrap'><form data-form_id=\"60004\" id=\"fluentform_60004\" class=\"frm-fluent-form fluent_form_60004 ff-el-form-top ff_form_instance_60004_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_60004_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Wholesale Dealer Account Application<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='31588' \/><input type=\"hidden\" id=\"_fluentform_60004_fluentformnonce\" name=\"_fluentform_60004_fluentformnonce\" value=\"71b4a9195b\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F31588\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-60004_1\" ><h3 style=\"text-align: center\"><strong><b>AmpGarden LLC<\/b><\/strong><\/h3>\n<p style=\"text-align: center\">Phone: +1 (321) 491-1688 Website: www.ampgarden.com<br \/>Email address: sales@ampgarden.com <br \/>2300 Hardwood Marsh Rd. Clermont, Fl. 34711 #276<\/p>\n<h2 style=\"text-align: center\"><strong>Wholesale Dealer Account Application<\/strong><\/h2><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_input_text' aria-label=\"Company Name\">Company Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_60004_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_input_text_1' aria-label=\"Legal Entity\">Legal Entity<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_60004_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_input_text_2' aria-label=\"Business Address\">Business Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_60004_input_text_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_60004_input_text_3' aria-label=\"Shipping Address (if different)\">Shipping Address (if different)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" data-name=\"input_text_3\" id=\"ff_60004_input_text_3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_phone' aria-label=\"Phone:\">Phone:<\/label><\/div><div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone ff_el_with_extended_validation\" type=\"tel\" placeholder=\"Mobile Number\" data-name=\"phone\" id=\"ff_60004_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_60004_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_input_text_4' aria-label=\"Primary Contact Name\/Title\">Primary Contact Name\/Title<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_60004_input_text_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_email_1' aria-label=\"AP\/Accounting Contact Email\">AP\/Accounting Contact Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_1\" id=\"ff_60004_email_1\" class=\"ff-el-form-control\" data-name=\"email_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_input_text_5' aria-label=\"Federal Tax ID \/ EIN\">Federal Tax ID \/ EIN<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" data-name=\"input_text_5\" id=\"ff_60004_input_text_5\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-60004_2\" ><h2><strong>Authorized Agent(s) (names + phone\/email):<\/strong><\/h2><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_input_text_6' aria-label=\"Name\">Name <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" data-name=\"input_text_6\" id=\"ff_60004_input_text_6\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_phone_1' aria-label=\"Phone:\">Phone:<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_1\" class=\"ff-el-form-control ff-el-phone ff_el_with_extended_validation\" type=\"tel\" data-name=\"phone_1\" id=\"ff_60004_phone_1\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_email_2' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_2\" id=\"ff_60004_email_2\" class=\"ff-el-form-control\" data-name=\"email_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_60004_input_text_7' aria-label=\"Name\">Name <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_60004_input_text_7\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_60004_phone_2' aria-label=\"Phone:\">Phone:<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_2\" class=\"ff-el-form-control ff-el-phone ff_el_with_extended_validation\" type=\"tel\" data-name=\"phone_2\" id=\"ff_60004_phone_2\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_60004_email_3' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_3\" id=\"ff_60004_email_3\" class=\"ff-el-form-control\" data-name=\"email_3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Requested Terms:\">Requested Terms: <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_62e36b244001e7a9152d62c3423e4d94><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Prepay\"  id='input_radio_62e36b244001e7a9152d62c3423e4d94' aria-label='Prepay' aria-invalid='false' aria-required=true> <span>Prepay<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_86690407d0941dbf6b2ecfcd012993cb><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Net 15\"  id='input_radio_86690407d0941dbf6b2ecfcd012993cb' aria-label='Net 15' aria-invalid='false' aria-required=true> <span>Net 15<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_20c6e872728e1be6d5a411e472c313c8><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Net 30\"  id='input_radio_20c6e872728e1be6d5a411e472c313c8' aria-label='Net 30' aria-invalid='false' aria-required=true> <span>Net 30<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_60004_input_text_8' aria-label=\"Requested Credit Limit: $\">Requested Credit Limit: $<\/label><\/div><div class='ff-el-input--content'><div class=\"ff_input-group\"><div class=\"ff_input-group-prepend\"><span class=\"ff_input-group-text\">$<\/span><\/div><input type=\"text\" name=\"input_text_8\" class=\"ff-el-form-control\" data-name=\"input_text_8\" id=\"ff_60004_input_text_8\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-60004_3\" ><p><strong>All Orders require the Authorized Signature of Buyer.<\/strong><\/p>\n<p>Dealer certifies the information provided is true and authorizes AmpGarden to verify trade\/bank references for credit evaluation. \u00a0Credit lines are granted based on accuracy and completeness of information provided and is subject to modification.<\/p><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-60004_4\" ><h3>Authorized Signer (Dealer):<\/h3><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Authorized Signer (Dealer):\">Authorized Signer (Dealer): <\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature_3' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_3_60004' \n            class='fluentform-signature-pad' \n            data-form-id='60004'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FFEB3B;\n                width: 100%;\n            '\n            height=\"100\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Please sign in the yellow area.<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Name\/Title:\">Name\/Title: <\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature_4' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_4_60004' \n            class='fluentform-signature-pad' \n            data-form-id='60004'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FFEB3B;\n                width: 100%;\n            '\n            height=\"90\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Please sign in the yellow area.<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Date:\">Date:<\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature_5' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_5_60004' \n            class='fluentform-signature-pad' \n            data-form-id='60004'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FFEB3B;\n                width: 100%;\n            '\n            height=\"90\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Please sign in the yellow area.<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-60004_5\" ><h3>Authorized Signer (AmpGarden):<\/h3><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Authorized Signer (AmpGarden):\">Authorized Signer (AmpGarden): <\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_60004' \n            class='fluentform-signature-pad' \n            data-form-id='60004'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FFEB3B;\n                width: 100%;\n            '\n            height=\"100\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Please sign in the yellow area.<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Name\/Title:\">Name\/Title: <\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature_1' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_1_60004' \n            class='fluentform-signature-pad' \n            data-form-id='60004'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FFEB3B;\n                width: 100%;\n            '\n            height=\"90\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Please sign in the yellow area.<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature_2' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_2_60004' \n            class='fluentform-signature-pad' \n            data-form-id='60004'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FFEB3B;\n                width: 100%;\n            '\n            height=\"90\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Please sign in the yellow area.<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-60004_6\" ><p>*Note: Any Inquiries about purchase for wholesale are to be referred to AmpGarden management. \u00a0<\/p><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\" >Submit Form<\/button><\/div><\/fieldset><\/form><div id='fluentform_60004_errors' class='ff-errors-in-stack ff_form_instance_60004_1 ff-form-loading_errors ff_form_instance_60004_1_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_60004_1 = {\"id\":\"60004\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"asteriskPlacement\":\"asterisk-right\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_60004_1\",\"form_id_selector\":\"fluentform_60004\",\"rules\":{\"input_text\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is 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required\",\"global_message\":\"This field is required\",\"global\":true}},\"email_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"email\":{\"value\":true,\"message\":\"This field must contain a valid email\",\"global_message\":\"This field must contain a valid email\",\"global\":true}},\"input_text_5\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_6\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"phone_1\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"},\"valid_phone_number\":{\"value\":true,\"global\":true,\"message\":\"Phone number is not valid\",\"global_message\":\"Phone number is not 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