Wholesale Pricing Request Form
Please fill out this form to request wholesale pricing for your business.
Contact Full Name
*
First Name
Last Name
Business Name
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Where is your company located?
*
State/Country
Industry or Market Focus:
*
Food & Beverage
Agriculture / Growing
Livestock / Animal Health
Healthcare
Clinical/Diagnostic
Water Treatment
Institutions
Other
Product Interest and Quantity
*
Estimated Monthly Quantities
Selectrocide 1G (2 Gal ClO₂ Disinfectant)
Selectrocide 5G (12.5 Gal ClO₂ Disinfectant)
Selectrocide 12G/A12 (30 Gal ClO₂ Disinfectant)
Clobberizer (Deodorizer)
Fast Release Gas (Deodorizer)
Extended Release Gas (Deodorizer)
Wide Range Test Strips
Low Range Test Stips
Other
Estimated Order Frequency:
*
Please Select
One-time purchase
Monthly
Quarterly
Annual
Other
Do you plan to resell or use these products internally?
*
Please Select
Distribution / Resell
Internal Use
Other
Estimated Start Date for Purchasing:
*
Please describe your intended use or application:
*
Any other details or requirements we should know about?
*
File Upload
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Appointment Availability
*
Please verify that you are human
*
Request Wholesale Pricing
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