Payment Portal Diverse Powered Brands Payment Form Upon receipt, diverse suppliers will be granted access to create their company and brand profiles in the marketplace. Email will provide you with user name and login details. If you need assistance, please email us at info@diversepoweredbrands.comName(Required) First Last E-mail(Required) Contact Number(Required)Job Title(Required)Company Name(Required)Company DBA if applicable(Required)Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What is your business?(Required) Wine Spirits RTD Non-Alc. Beer Sake Mixers Other Total Number of Brands to RegisterOther?Please specify.Annual FeesSelection - Wine My company produces wine Wine - Total Gallons Produced CY 2022(Required)Choose One< 2,3802,381 - 5,9505,951 - 23,80023,801 - 119,000119,001 - 47,600047,6001 - 1,190,0001,190,001 - 2,380 ,0002,380,001 - 7,140,0007,140,001 - 14,280,00014,280,001 - 238,000,000> 238,000,001Selection - Spirits My company produces spirits Spirits / RTD - Total Gallons Produced CY2022(Required)Choose One< 2,3802,381 - 5,9505,951 - 23,80023,801 - 119,000119,001 - 476,000476,001 - 1,190,0001,190,001 - 2,380 ,0002,380,001 - 7,140,0007,140,001 - 14,280,00014,280,001 - 238,000,000> 238,000,001Selection - Beer My company produces Beer / RTD / Hard Seltzer Brewers - Total Barrels - CY 2022(Required)Choose One< 10001,001 - 7,5007,501 - 15,00015,001 - 30,00030,001 - 60,00060,001 - 100,000100,001 - 500,000500,001 - 1,000,0001,000,001 - 1,999,9992,000,000 - 6,000,000> 6,000,001Selection - non My company produces Non-Alcoholic / Mixers - Annual Fee Non-Alc / Mixers - Total Gallons Produced CY 2022(Required)Choose One< 2,3802,381 - 5,9505,951 - 23,80023,801 - 119,000119,001 - 476,000476,001 - 1,190,0001,190,001 - 2,380,0002,380,001 - 7,140,0007,140,001 - 14,280,00014,280,001 - 238,000,000> 238,000,001Total Fees Price: $0.00 Enter Coupon Total Credit CardCard Details Cardholder Name
