Mineraali Vendor Registration Form

Vendor Registration Form

Thank you for your interest in doing business with Mineraali. To be considered as a potential reseller or online retailer, please complete this form in its entirety!
Initial Registration / Sign up

Please complete the form below to register your company.
Legal Company Name*
Name of the company as it appears in legal registration.
DBA/Trade Name
Doing Business As (if any)
Corporate Headquarters - US*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Company Phone*
Please enter a valid phone number.
Company Fax
Please enter a valid phone number.
Company Email*
example@example.com
Company Website*
www.example.com
DUNS Number
(Please enter your business D‑U‑N‑S number)
Are you a certified diverse?*

YesNo
Selling Mineraali products through online marketplaces?*

YesNo
Does your business has Sales Tax Exemption?*

YesNo
If yes to the above question, please upload copy of your Sales Tax Exemption:

Cancelof
Primary Contact
Contact Name*

First NameLast Name
Title*
job title of the primary contact
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Phone*
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email*
example@example.com
Please verify that you are human*
Should be Empty:

Vendor Registration Form