Wholesale Application

Wholesale Application

Thank you for your interest in carrying PrimeKinetix products. If you have any questions or concerns, please call 8772151124 to speak with Cheetah.
Primary Contact Name (Account Holder)*

First NameLast Name
Name of Business*

Legal NameDBA or AKA
Website
Tax ID*
Please enter valid Tax ID #
Phone Number*
Please enter a valid phone number.
Sign me up for SMS Marketing Specials*

YesNo
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail *
What Type of Business are you?

Chiropractic ClinicMassage Therapy ClinicPhysical Therapy ClinicAthletic Team or OrganizationOther (Please Specify in Notes)
Notes
Average Number of Clients Seen Daily?
What's your T-shirt Size?
How did you hear about us?*
Upload a copy of your Resale Certificate/License

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I certify that all information provided is true and accurate.
Signature*

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Date

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Date
Terms & Conditions: All information collected is confidential.

If approved, you will receive a customer number and your login username via email.

Most request are approved same day, but occassionally submissions may take up to 48 business hours.
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