Application for New Wholesale Partner

If you have any issues completing this form, please reach out to our Sales Team for assistance. 

Company Information *

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Checkboxes

• Check here is Billing Address is the same as Shipping Address

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Tax ID Number

Company URL *

Social Media Outlets

Social Media Outlets

• Instagram
• Twitter
• Snapchat
• Facebook
• Tiktok
• LinkedIn

Payment Methods

Payment Methods

• Charge (Visa, MC, AMEX, Discover)
• Purchase Orders
• ACH Bank Transfer

Purchaser/Point of Contact Information *

First

Last

Point of Contact Email Address *

Point of Contact Phone Number *

Checkboxes (copy)

• Check here if Purchaser/Point of Contact is Owner of Company

Number of cases Requested for your First Order (Case Count: 6 Units) *I Purchased at SuperZoo 2022Please Contact Me Directly1 Case2 Cases3 Cases4 Cases5 Cases10 Cases20 Cases25 Cases50 Cases

Owner's Information *

First

Last

Owner's Email Address *

Owner's Mobile Number *

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 and abide by our Internet Minimum Advertised Pricing (IMAP) policy. 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.

Submit

By submitting this, I certify that all the information listed 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 and abide by our Internet Minimum Advertised Pricing (IMAP) policy. I understand that Genie’s Therapeutics reserves the right to reject or terminate at any time. This application does not grant credit terms. A separate form is available for this purpose.