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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 *

Email Address *

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
Fitness
Health Food Store
Mobile Care
Personal Use Only
Pharmacy
Residential Practice
Spa
Sports Medicine
Supplements
Veterinary
Wellness Center
Primary Sales Channel
Mail Order
Mass Market Retail
Practitioner
Telephone
TV/Radio

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!