US Wholesale Application form

US Wholesale application

To apply for our US Wholesale program please complete all questions.
Company Name*
Name*

First NameLast Name
Contact title *
Company address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Do you have a website? Yes or No. If Yes, please include URL. *
Will you sell products in the store or office location you do business at? *
Will you sell products online? This would be your website URL, 3P platform selling is not allowed. *
IP address for your website. Please input NA if you do not have a website. *
What type of business do you have, retail store, spa, physician, etc.? *
How did you hear about Vimergy? *
See the link below to review Terms and Conditions prior to submitting your application.*

I have not reviewed the terms and conditionsI have reviewed and agree to the terms and conditions
Signature*
Signing Date*

MonthDayYear
Date
Should be Empty:

US Wholesale application