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Application for New Wholesale Partner

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By submitting this application, I certify that all the information listed on this application is accurate and true to the best of my knowledge. In addition, I acknowledge and understand that the wholesale agreement is strictly offered to customers intended to resell Genie's Therapeutics products. I understand that Genie's Therapeutics reserves the right to reject this application or terminate it at any time. This application does not grant credit terms. A separate application form is available for this purpose.