Wholesale Account Application
Company Information
Legal Business Name
*
DBA
State Tax ID Number
*
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Business Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Fax Number
-
Area Code
Phone Number
Primary Business Email Address
*
example@example.com
Back
Next
Business Presence
*
Brick & Mortar
Brick & Mortar + Online Direct Website
Brick & Mortar + Online Marketplace Platform
Online - Direct Website
Online - Marketplace Platform
Business Type/Industry
*
Health Food Store
Gym/Fitness Center/Spa
Natural Health Food Store
Holistic Wellness Store
Government Agency
Educational Facility
Athletic Association
Online Health Food Store
Online Natural Health Food Store
Online Holistic Wellness Store
E-Commerce/Marketplace Retailer
Smoothie Bar
Personal Trainer
Grocery Store
General Merchandise Store
Distributor/Sub-Distributor
Other: Please Describe Below
List "Other" Business Type/Industry
Brick & Mortar Sales %
*
Online Sales %
*
Anticipated Order Frequency
*
Weekly
Bi-Weekly
Monthly
Quarterly
Yearly
Other: Please Sepcify Below
List "Other" Anticipated Order Frequency
Anticipated Monthly Sales
*
Back
Next
Department Contacts
Owner
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Manager
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Accounts Payable
*
First Name
Last Name
Invoice Remittance Email Address
*
example@example.com
Statement Remittance Email Address
*
example@example.com
Authorized Purchaser 1
First Name
Last Name
Authorized Purchaser 2
First Name
Last Name
Authorized Purchaser 3
First Name
Last Name
Purchasing Contact
First Name
Last Name
Purchasing Contact Email Address
example@example.com
Marketing Contact
First Name
Last Name
Marketing Contact Email Address
example@example.com
Social Media Contact
First Name
Last Name
Social Media Contact Email Address
example@example.com
Warehouse or Receiving Contact
First Name
Last Name
Warehouse or Receiving Contact Email Address
example@example.com
Back
Next
Social Media & Other Online Presence
FaceBook URL/ID
Twitter URL/ID
Instagram URL/ID
Pinterest URL/ID
YouTube URL/ID
LinkedIN URL/ID
SnapChat URL/ID
Amazon Marketplace URL/ID
Walmart Marketplace URL/ID
Ebay Marketplace URL/ID
Rakuten Marketplace URL/ID
Other Marketplace URL/ID
Back
Next
Days of Operation (Please check all that apply)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunda
Normal Business Hours
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
Delivery Hours of Operation
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
Special Delivery Requirements (Please check all that apply)
*
None
Lift Gate
Inside Delivery
Lift Gate + Inside Delivery
Residential Delivery Address
Additional Delivery Requirements or Comments
Attach a Formal Copy of your retail sales or Business License Here
*
Browse Files
For states that do not issue a business license, please attach a copy of your state's tax exemption form.
Cancel
of
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm