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Wholesale Account Application

Thank you for your interest in our products.

To get started, please take some time to review the Wholesale Account Qualifications before proceeding with the form. Please also review our Reseller Agreement and USMAP Policy.

First Name *

Last Name *

Title *

Website *

Company Name *

Address *

Address 2

City *

State (select) *

Country Code (select) *

Postal/Zip Code *

Phone Number *

Billing Address (if different)

Billing City

Billing State (Select)

Billing Postal Code

Billing Contact *

Billing Email *

Primary Business Type

Primary Sales Channel

Practitioner Type *

Referral *

Reseller Agreement *

USMAP Policy *

Please Note: Your application will not be reviewed until we receive your business or professional license, and Tax and Use Resale Certificate.
Please fax a copy to 512-371-6574 or email to Qualified wholesale accounts are typically established within 3 business days.

Thank you for your interest in our line of products. We look forward to a long and prosperous partnership!