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Wholesale Account Application Form

To establish a wholesale account with us and access our website at www.wholesale.healthmobius.com, you will need to register your account and complete the following forms. We will quickly process your application and contact you when your account has been reviewed. For assistance with filling out the application, feel free to call us at 630-325-5150.
Please note you MUST provide the User ID (log in name) you created on our website as well as all websites you will be selling on.
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ACKNOWLEDGEMENT AND ACCEPTANCE OF HEALTH MOBIUS POLICIES

I agree to comply with the Health Mobius Policies and Website terms and conditions as updated from time to time, including but not limited to:
  1. Following Minimum Advertised Price (MAP), when it exists.
  2. Identifying, disclosing and requesting permission to resell products purchased through Health Mobius. This shall include requesting & obtaining express permission for each and every website and identifying all user names, DBA, telephone numbers and addresses related to any seller account or website related to you.
  3. Not listing products on any marketplace without written permission from Health Mobius. See “Policy for Resellers” on the website for more details.
List all Websites and all channels you sell on including your DBA & Seller Name on each channel:
List all names, addresses,and telephone numbers of any related entities:

UNIFORM SALES & USE TAX EXEMPTION/RESALE CERTIFICATE – MULTIJURISDICTION

The below-listed states have indicated that this certificate is acceptable as a resale/exemption certificate for sales and use tax. The issuer and the recipient have the responsibility to determine the proper use of this certificate under applicable laws in each state, as these may change from time to time.
Health Mobius LLC
260 Shore Ct, Burr Ridge, IL 60527
I certify that
is engaged as a registered

and is registered with the below-listed states and cities within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, or ingredients or components of a new product or service to be resold, leased, or rented in the normal course of business. We are in the business of wholesaling, retailing, manufacturing, leasing (renting) selling (California) the following:

State State Registration, Seller’s Permit, or ID Number of Purchaser State State Registration, Seller’s Permit, or ID Number of Purchaser
AK Provide EIN# Below. MT Provide EIN# Below.
AL NC
AR ND
AZ NE
CA NH Provide EIN# Below.
CO This form dose not apply. Use Colorado State Form DR-0563. NJ
CT NM
DC NV
DE Provide EIN# Below. NY This form dose not apply. Use New York State Form ST-120.
FL This form dose not apply. Use Florida State Form DR-97. OH
GA OK
HI This form dose not apply. Use Hawali State Form G-17. OR Provide EIN# Below.
IA PA
ID PR This form dose not apply. Use Puerto Rico State Form AS-2916.1
IL This form dose not apply. Use Illinois State Form CRT-61 RI
IN This form dose not apply. Use indiana State Form ST-105. SC
KS SD
KY TN
LA This form dose not apply. Use Louisiana State Form R-1042. TX
MA This form dose not apply. Use Massachusetts State Form ST-4. UT
MD VA This form dose not apply. Use Virginia State Form ST-10.
ME VT
MI WA
MN WI
MO WV This form dose not apply. Use West Virginia State Form WV/CST-280.
MS This form dose not apply. Use State of Mississippi Resale Certificate. WY This form dose not apply. Use Wyoming State Tax Exemption Certificate.

For buyers with locations in states that do not require state tax registrations, please check the appropriate box (es) and supply your federal EIN#:

I further certify that if any property or service so purchased tax free is used or consumed as to make it subject to a Sales or Use Tax we will pay the tax due directly to the proper taxing authority when state law so provides or inform the Seller for added tax billing. This certificate shall be a part of each order that we may hereafter give to you, unless otherwise specified, and shall be valid until canceled by us in writing or revoked by thee city or state. Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter.

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