Wholesale Registration

Wholesale Application

First Name*

Last Name*

Practice Name*

Address 1*

Address 2

City*

State/Province/Region*

Zip/Postal Code*

Country*

Phone*

Type of Practice

State License #*

Website URL*

Where did you hear about us?*

Login Information

Email*

Password*

Confirm Password*

Desired Pricing Level

Retail
Wholesale

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

Agreement

By signing below, I confirm I am a healthcare practitioner opening a wholesale account with Kajarin. I authorize Kajarin to charge my credit card for all amounts that I owe and any and all recurring transactions. I have read, understand and accept all shipping and order fulfillment policies.

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

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Wholesale Registration

Wholesale Application

Login Information

Desired Pricing Level

Agreement