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Resync Registration Form For A Wholesale Account

Thank you for being interested in carrying Resync products within your facility/practice.

Applications take 2 business days for approval. A Resync representative will reach out to you if any additional information is required. Upon approval, you will be provided with our wholesale pricing sheet, which details how to place orders.

If you have any additional questions, please contact Breanna@resyncproducts.com or call our office at 561-469-7655. We look forward to serving you. Thank you!

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* 1. Company Informaiton

Name

Legal Company Name

Full Business Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Type Of Business/Practice

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* 3. Date Started

Date / Time

Date

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* 4. Number of Employees

1-10

11-50

51-100

100+

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* 5. Name of Owner With Title & Email Address

Name

Title

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* 6. Accounts Payable Informaiton

Name

Phone Number

Email Invoices To

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* 7. Please Select One

Corporation

Individual

LLC

Partnership

Other (please specify)

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* 8. State or Country Incorporated

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* 9. Tax ID Number (EIN)

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* 10. Organization DUNS Number

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* 11. Intention of Distribution (select all that apply)

Resell within practice

Resell on website

Recommend to patients

Sample to patients

Personal Use

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* 12. Please Select One Of The Following (submit documents In next section)

Wholesale Account - Please submit Wholesale License (wholesale permit, sellers permit or wholesale ID)

Resale Account - Please submit a copy of your Resale Certificate

Tax Exempt - Please submit a copy of Sales Tax Certificate of Exemption for ALL applicable states

Non Tax Exempt - Applicable taxes will be charged (unless Sales Tax Exemption Certificate is provided)

Business License - Please submit a copy

Other (please specify)

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* 13. Please Up Load Your Documents Here or Email Your Documents To Breanna@resyncproduts.com

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 14. Please Provide Trade References (#1)

Contact Name

Company Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 15. Please Provide Trade References (#2)

Contact Name

Company Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 16. By Submitting This Information You:

Confirm this information is accurate and up to date

Confirm the submitted documents are accurate and truthful

Are an authorized representative of this organization and have authority to apply for a wholesale account

Check this box as an electronic signature