*Wholesale Account Information*
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
Fax Number
Primary Business Email Address
*
example@example.com
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Business Presence
*
Brick & Mortar
Brick & Mortar + Online Direct Website
Brick & Mortar + Online Marketplace Platform
Online - Direct Website
Online - Marketplace Platform
Business Type/Industry
*
Corporate Hospital Chain
Independent Hospital
Corporate Weight Loss Clinic
Independent Weight Loss Clinic
Corporate Surgery Center
Independent Surgery Center
Corporate Bariatric Clinic
Independent Bariatric Clinic
Corporate Dialysis Clinic
Independent Dialysis Clinic
Corporate Pharmacy
Independent Pharmacy
Cancer Center
Independent General Practitioner
Corporate Registered Dietitian
Independent Registered Dietitian
Corporate Chiropractor
Independent Chiropractor
Holistic Practitioner
Naturopathic Practitioner
Corporate Bariatric Support Group
Independent Bariatric Support Group
Corporate Dialysis Support Group
Independent Dialysis Support Group
Dentist
Corporate Physical Therapy Center
Independent Physical Therapy Center
Independent Physical Therapist
Nurse Practitioner
MD
Registered Nurse
Women's Health & Wellness Clinic
Family Medicine Practitioner
Government Health Agency
Medical Educational Facility
E-Commerce Marketplace Retailer
Other: Please Specify Below
List "Other" Business Type/Industry
*
Brick & Mortar Sales %
*
Online Sales %
*
Anticipated Order Frequency
*
Weekly
Bi-Weekly
Monthly
Quarterly
Yearly
Other: Please Specify Below
List "Other" Anticipated Order Frequency
Anticipated Monthly Sales
*
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*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
Accounts Payable Phone Number
*
-
Area Code
Phone Number
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
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*Social Media & Other Online Presence*
Facebook URL/ID
Twitter URL/ID
Instagram URL/ID
Pinterest URL/ID
YouTube URL/ID
LinkedIn URL/ID
SnapChat ID
Amazon Marketplace URL/ID
Walmart Marketplace URL/ID
Ebay Marketplace URL/ID
Rakuten Marketplace URL/ID
Other Marketplace URL/ID
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Days of Operation (Check all that Apply)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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 (Check all that Apply)
*
None
Lift Gate
Inside Delivery
Lift Gate + Inside Delivery
Residential Delivery Area
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. Blank forms will be rejected.
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