Wholesalers – Vital Bloom with Viilexa

Business Type:

Others Business Type

Resale Certificate Number

Healthcare License Number (if applicable):

NPI Number (if applicable)

2. Business Category

Please select your account type

4. Shipping Information (if different)

Shipping Company Name (if different)

5. Contact Information

Primary Contact Name

Website/Online Store URL

Marketplace Accounts (if applicable)

Amazon Shopify Walmart Other

Other Marketplace Accounts Name

6. Purchasing & Distribution Information

Estimated Monthly Purchase Volume: $

Products of Interest

Do you intend to resell internationally?

Yes No

Do you agree to comply with MAP pricing (if applicable)?

Yes No

Do you require Net Terms?

Yes No

If yes, requested terms

7. Compliance & Certification

For healthcare product distribution, please confirm:

All products will be stored according to manufacturer guidelines All products will be sold only to authorized customers You comply with local, state, and federal healthcare regulations You will not alter packaging or labeling

8. Agreement & Signature

I certify that the information provided is accurate and complete. I understand that approval is subject to verification and compliance review.

WHOLESALE ACCOUNT APPLICATION FORM

PHARMILEX HEALTHCARE INC.

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