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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 (Uppercase Two-Letter Abbreviation) *


 
Country *


 
Postal/Zip Code *


 
Phone Number *


 
Billing Address (if different)


 
Billing City


Billing State


 
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 wholesale@enviromedica.com. 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!