wholesale account registration

First Name *

Last Name *

Email *

Business Name *

Business Type *

Street Address *

Address Line 2

City *

State / Province / Region *

ZIP / Postal Code *

Country *

Tax ID/EIN *

Practitioner ID *

Phone Number *

Projected Monthly Sales *

Additional Infomation

Upload Reseller or Practitioner License *

Username *

Password *

Enter Password *

Confirm Password *

I agree that I will NOT attempt to sell any Methyl-Life products on Amazon, Google, Walmart, Jet, Ebay or other public online markets. I will only use my own online websites and/or brick and mortar stores.*

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