Wholesale Application Form - Herbal Connection

1

Business Name* This field is required.Please enter the name of your business

2

Business ABN/ACN* This field is required.Please enter the registered ABN or ACN for your business

3

Email* This field is required. Please enter the email address you used to register your online account, we will also contact you via this email

example@example.com

4

Business Website Not required, but if you have a website URL please feel free to enter here

5

Phone Number* This field is required. Please enter your preferred contact phone number

Please enter a valid phone number.

6

Business Representative Name* This field is required. Name of contact that represents this business (example; owner or manager etc)

First Name

Last Name

7

Business Type* This field is required.Please select the category that best matches your business

Distillery

Hospitality

Manufacturer

Practitioner

Tea Blender

Wholefoods/Healthfoods

Wholesaler

8

Anticipated Monthly Spend* This field is required.What you anticipate to spend per month with the Herbal Connection

Under $500

$500 - $1,500

$1,500 - $3,000

$3,000 - $5,000

Over $5,000

9

Home Address or Business Address* This field is required.Is your delivery address for orders a home address, or business address? Some couriers only deliver to a business address so this information helps us avoid errors!

Home Address

Business Address

10

Are You A Business With Multiple Ordering Locations, Requiring Each Location To Have A Separate Account For Ordering?* This field is required.Example; Healthfood Store Franchise

YESNO

11

Do You Require A COA Sent With Your Goods?* This field is required. Many manufacturers may require a COA (Certificate of Analysis) sent with the goods

YESNO

12

Do You Require An Invoice Sent With Your Goods?* This field is required. This can be important for certain stores to receive an invoice to check off items - by default we don't send an invoice with your order because it is available via the website, and we are conscious of paper usage to reduce waste

YESNO

13

Request Further Discussion Would you like a member of the Herbal Connection team to contact you via phone or email, to discuss any extra questions and assist with your on boarding process? If so, feel free to enter appropriate time or date for a phone call