Company Name *

Sales Tax ID #:

Primary Contact Name *

Email Address *

Company Website

Phone # *

Shipping Address *

Billing Address

NuEthix Sales Rep Name

Preferred Method of Payment (Please check ONE) *

Credit Card (invoices will be emailed after order is placed; order does not ship until invoice is paid)

ACH (invoices will be emailed after order is placed; order does not ship until invoice is paid)

Upload Sales Tax Certificate

(if applicable)

Upload Practitioner/Coaching Certificate

(if applicable)

***NOTE: Distributors are NOT permtted to sell products online OTHER THAN on the company website listed above. All other sites must be approved by NuEthix first or you may lose your wholesale rights.

Would you like your store to be added to out store locator on our website?

If your STORE NAME, STORE ADDRESS, or STORE PHONE NUMBER are different from above, please specify here:

Please EMAIL all orders to [email protected] and include the following:

Product Name, quantity, and flavor (if applicable)
*Preferred shipping method (only needed if overnight/express shipping is being requested)
*Shipping address (only needed if different from address on your account OR if you have multiple addresses/locations)