Wholesalers/Marketers/Investors

If you are a wholesaler interested in carrying our products or marketing our products, or becoming and investor in the growing fields – great! Please complete the following information, and someone will contact you shortly!

Fieldset

First Name *
Last Name *
Business Name
Please Check All That Apply *
WholesalersMarketerInvestor
Email Address *
Business Type *
Single LocationMultiple LocationDistrubutor
Phone Number *
How did you hear about bioRemedies MD/KBConnections *
InternetFriendSocial mediaOther
Do you currently purchase bioRemedies MD products? *
Yes (directly)Yes (via distributor)No
EIN: Tax ID number
Industry *
DistributorWellness CenterSmokeshop/VapeshopHealth Food StoreHealthcare ProviderChiropractorAcupuncturistFitness CenterOther
*If yes, from who?
Product of Interest *
TopicalsSublingual DropsVaporizers/OilPet Products
ARE YOU BORN IN OR AFTER 1998
YESNO

Verification

Please enter any two digits *Example: 12
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