Wholesale form

Wholesalers Application

Business Information:

Legal Business Name

Doing Business As (DBA)

Business Phone

Business Address

Country

State/Province

City

Zip Code

Website

Owner/Main Contact Information:

Full Name

Position/Title

Contact phone

Contact Email

Business Details

Type of Business

Years in business

Tax ID or Business License Number

DUNS Number

Expected Monthly Purchase Volume

References

Supplier/Brand Reference 1:

Name

Contact

Phone

Supplier/Brand Reference 2:

Name

Contact

Phone

Marketing and Promotion:

Do you plan to sell Dermelect products online?

Yes

Please list website(s):

Do you plan to use Dermelect's brand name in advertising or promotions?

Yes

Attachments:

Please attach a copy of your business license (if applicable). Allowed File types are [.jpg,.jpeg,.png,.heic,.pdf]. Maximum upload size is 10MB

Please attach a copy of your resale certificate (if applicable). Allowed File types are [.jpg,.jpeg,.png,.heic,.pdf]. Maximum upload size is 10MB

Additional Notes/Comments:

By checking this you agree to not sell our products on Amazon