Distributor Account Application

Wholesale Program — Priority Pricing — Dedicated Support. Distributor accounts are reviewed within 1-2 business days.

Distributor Type

USA Distributor International Distributor

1. Company Information

Legal Company Name *

Trade / DBA Name

EIN / Tax ID *

Year Established

State of Incorporation

Website

2. Business Address

Street Address *

City *

State *

ZIP Code *

County

Country *

3. Primary Contact

First Name *

Last Name *

Job Title

Business Email *

Phone *

WhatsApp / Telegram

4. Distribution Profile

Distribution Channels *

Clinics & medical practices

Medical spas

Gyms & wellness centers

E-commerce

B2B wholesale

Retail store

Pharmacy

Import / re-export

Other

Estimated Monthly Order Volume *

Active Clients / Accounts

Territory Covered

Current Product Lines / Suppliers

5. A Few Quick Questions

How did you hear about us?

Partner / Referral Code

Anything else you'd like us to know?

6. Declaration

I confirm the information provided is accurate and I am authorized to represent this company. I agree to the Distributor Terms & Conditions and understand that pricing and credit terms are subject to approval. *