Holocuren.com | Wholesale Signup

Questions? Contact our customer service center at 702.333.5980 or support@holocuren.com

WHOLESALE APPLICATION

*First Name:		*Last Name:

Company:

*Address 1:

Address 2:

*City:

*State/Province/Region :		*Zip/Postal Code :

*Country:

*Daytime Phone:		Evening Phone :

Fax:

Where did you hear about us?

*Email:

*Password:

*Confirm Password :

DESIRED PRICING LEVEL

wholesale tier

Please describe your business, where our products will be sold, and any other pertinent information to your application.

AGREEMENT

By clicking Submit, I hereby certify, that I hold a valid seller's permit and all product purchased from this website through this account will be used for resale purposes only.

Once your application is reviewed, you will receive confirmation of approval by email.

* I have read, understand, and agree to the above agreement. :