Wholesale Application

Are you the owner of manager of a smoke shop, health shop, or other retail outlet? Are you a distributor? If you’re interested in selling Total Health Cleanse™ Detox Program, we’re interested in talking with you! Please fill out the form below to sign up for a wholesale account.

A sales rep will contact you within 48 hours. (Excluding weekends)


* Denotes required field




 

Business Name (no DBAs) *

Federal EIN *

 

Contact Person

First Name *

Last Name *

Phone Number *

Email Address *

 

Billing Address

Street Address *

Street Address 2

City *

State *

Zip/Postal Code *

 

Shipping Address

Street Address

Street Address 2

City

State

Zip/Postal Code

 

Business Reference 1

Business Name *

Contact Person *

Phone Number *

 

Business Reference 2

Business Name *

Contact Person *

Phone Number *

 

Business License or Articles of Incorporation

If you have a copy of your business license or articles of organization you can attach it here to streamline your application process.
Accepted file types: PDF, JPG, JPEG, DOC, RTF


 

Security Check

captcha
 

Type the characters shown in above image.


By Clicking the Submit button below, you agree that The Herb Company may use the information included with this form to verify that you represent a business licensed to operate in your jurisdiction. You further grant permission for The Herb Company to contact your references in order to establish creditworthiness. In addition you indicate that you have read and agree to the terms of our Reseller Agreement.
 
I agree to these terms and conditions.