Wholesale Account Application Form

Company Name:

Nature of Business:

Email Address:

Main Website:

Street Address:

City:

State:

Zip:

Phone: - Area Code Phone Number

User ID:

Buying Group Member?

MHA/MED/Navigator

Other:

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:

Following Minimum Advertised Price (MAP), when it exists.
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.
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.

Issued to Seller:Health Mobius LLC

Address260 Shore Ct, Burr Ridge, IL 60527

I certify that

Name of Firm (Buyer)

Address

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:

Description of Business

General description of tangible property or taxable services to be purchased from the Seller

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#:

AK DE MT NH OR 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.

First Name

Last Name

Title

Date

Month Day Year

Wholesale Account Application Form

ACKNOWLEDGEMENT AND ACCEPTANCE OF HEALTH MOBIUS POLICIES

UNIFORM SALES & USE TAX EXEMPTION/RESALE CERTIFICATE – MULTIJURISDICTION

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