Wholesaler Registration

LEGAL NAME*

TRADE NAME*

ADDRESS ONE*

ADDRESS TWO

CITY*

STATE*

ZIP*

PHONE*

FAX*

CONTACT PERSON NAME*

CONTACT PERSON TITLE*

VAWD*

CUT OFF TIME*

Terms*

Wholesalers Shipping

Ground

Minimum order Amount

Shipping Fee

2nd Day

Minimum order Amount

Shipping Fee

Same Day

Minimum order Amount

Shipping Fee

OVERNIGHT

Minimum order Amount

Shipping Fee

Discount Section

Minimum

Minimum Amount Met

Discount Rate (%)

Maximum

Maximum Amount Met

Discount Rate (%)

EMAIL ADDRESS*

PASSWORD*

CONFIRM PASSWORD*

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Verification Code*

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