Wholesale Account Application Form

Wholesale Application Form

Unit Dose, Ltd - Dr. Linda H. Dixon, M.D.
Business Name
Personal Contact Name
First and Last Name
Phone:
Format: (000) 000-0000.
E-mail:
example@example.com
Website:
Instagram or Social Media Address:
Please type full address, i.e. www.instagram.com/pmunumbing or www.facebook.com/kolorsourcellc, if you have more than one, please list those.
Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trading since

MonthDayYear
Type of Business
Please explain what exactly your company does.
Preferred Payment
Please upload a copy of your business license or resale tax license, showing that you are allowed to sell in your state/country.

Cancelof
Check all of our products that you are interested in purchasing wholesale:
Business Representative Information
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number
Format: (000) 000-0000.
Message

0/500
Do you understand that you are not allowed to re-sell topical anesthetics on 3rd party sites, such as Amazon, Wish, or eBay? Type "YES" if you understand.
You must type "Yes" that you acknowledge this. Selling our topical anesthetics on 3rd party sites will ban you from conducting business with our company.
I certify that the above information is true to the best of my knowledge. I understand that I subject myself to losing my business relationship with Unit Dose, Ltd., in the event that the above facts are found to be falsified.
Should be Empty:

Wholesale Application Form

Business Representative Information