Wholesaler onboarding form Email* [email protected] Company Information Please provide your Company's basic information Legal company name* State where Company is registered* Please Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming E.I.N. or T.I.N.* Is your company tax-exempt?* Please Select Yes No Upload certificate of tax-exemption* Browse FilesDrag and drop files here Choose a file Cancelof D/B/A (if applicable) Type of business* Please indicate your principal business type (e.g., physician's office, private training facility, etc) Website* Shipping address* Street Address Street Address Line 2 CityState / Province Postal / Zip Code Billing Address if different from shipping Street Address Street Address Line 2 CityState / Province Postal / Zip Code Contact name / responsible individual Name* First NameLast Name Phone Number* Please enter a valid phone number. Email* [email protected] Back Next Billing Account payable contact Name* First NameLast Name Phone Number* Please enter a valid phone number. Email* [email protected] Payment Method* ACHWireCredit Card (a 3.3% fee may apply) This fillable form does not guarantee acceptance of an order, it does not serve in lieu of an official issued invoice. Please provide FedEx or UPS account if desired. Shipping is charged at time of final invoice. Orders over 20 cases are considered freight and require FOB arrangements. Invoices must be paid within 72 hours to guarantee order processing. Delivery Timeline: Orders are expected to ship within 5-7 business days from date of order confirmation. Orders are nonrefundable. You must notify us on the day of delivery for damage or missing products. For full terms and conditions, visit www.hometestbox.com/terms Signature* Powered by Jotform Sign Clear SubmitSubmit Should be Empty:
