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Home » Wholesale Application

Wholesale Application

Company Information

Legal Name of Company *

DBA

Federal Tax ID *

Year Established *

Number of Locations *

Business Entity *

Sole Proprietorship Corporation Partnership LLC Other

Website (if not applicable, please enter n/a) *

Type of Business *

Retail Store Online Store Office (dental, medical, etc) Buyer's Club

How did you hear about us (who referred you)? *

Company Address Information

Billing Street Address 1 *

Billing Street Address 2

Billing City *

Billing State *

Billing Postal Code *

Billing Country *

Shipping Street Address 1 *

Shipping Street Address 2

Shipping City *

Shipping State *

Shipping Postal Code *

Shipping Country *

Company Contact Information

Primary contact/Buyer First Name *

Primary contact/Buyer Last Name *

Primary Contact/Buyer Email *

Primary Contact/Buyer Phone *

Would you like to be listed on our store locator so we can tell customers where to find you?

Accounts Payable Name *

Accounts Payable Email *

Accounts Payable Phone *

President/Owner Name

President/Owner Email

President/Owner Phone

Names of Authorized Buyers *

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the wholesale account for above stated company with OraWellness LLC. Furthermore, if selling online, I agree to the OraWellness Minimum Advertised Price (MAP) Policy. Details of the OraWellness MAP Policy can be found at OraWellnessWholesale.com/MAP. *

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