Wholesale Request Form

Store Name *

Buyer Name *

Contact First Name *

Contact Last Name *

Contact Phone 1 *

Contact Phone 2 *

Contact Email *

Store Address *

Address 2

Store City *

Please list all trade names under which HHPLIFT products will be sold: *

Please list all websites where HHPLIFT products will be sold: *

State/Province *

Zip/Postal Code *

Are you an Amazon FBA Seller? *

YES

NO

Preferred way to contact *

Phone

Email

Any

Please upload your reseller certificate *

Terms and Conditions *

You consent to receive communications from us electronically. We will communicate with you by e-mail or phone. You agree that all agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.

Signature *

clear

Date * +