New Customer Application | Wellness Products

Become A Retailer

"*" indicates required fields

1Retailer

2Shipping

Legal Business Name*

Operating As*

Business Type*

Corporation

Partnership

Proprietorship

Years in Business*

Payment Preference*

EFT

Cheque

Credit Card

Billing Address*

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Select Province

Phone Number

Website URL

Accounts Payable Contact Name*

First Last

Accounts Payable Email*

Accounts Payable Phone*

Accounts Payable Phone Extension

Buyer - Contact Name*

First Last

Buyer - Contact Email*

Buyer - Contact Phone*

Buyer - Contact Phone Extension

Additional Buyer - Contact Name

First Last

Additional Buyer - Contact Email

Additional Buyer - Contact Phone

Additional Buyer - Contact Phone Extension

Is your shipping address the same as your billing address?*

Yes

Shipping Address*

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Select Province

Shipping Email

Shipping Phone Number

Shipping Phone Number Extension

Receiving Hours*

Special Shipping Instructions