Wholesale Registration Form
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Business Information
Business Name
*
Industry
*
Business Type
*
Business Phone
*
Business Email
*
Email
Confirm Email
Business Address
*
Address Line 1
City
— Select state —
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Person
Layout
Name
*
Phone
*
Who is your sales person
*
— Select Choice —
None
Aleks
Nancy
Thomas
Gilliane
John
Maria
Who reach out to you in the past
Position
*
Email
*
Business Documentation
Reseller ID
Tax ID or VAT Number
Average Monthly Order Quantity
Terms and Conditions
Checkboxes
*
Buyer hereby accepts these
Terms
and has executed these Terms as of the date written below.
Signature
*
Clear Signature
Number Checkboxes Business
Date
*
Submit