2250 N. University Pkwy. #4822 o Provo, Utah [84604] o contact@pro-techealthresource.com o 208-977-8102

Application for Wholesale Purchasing

Annual Volume - $500 minimum

Date: _______________________

Name: _____________________________________________________________ Last/ First /Middle Initial

Address: ____________________________________________________________ (Street and / or PO Box)

City: __________________________________ State: ______ Zip: _____________

Phone: ____________________________ Fax: _____________________________

Email Address: ______________________________________________

Credit Card#: ________ - ________ - ________ - ________ Exp. Date ____ / ____

Business Name: _____________________________________________________

Mailing Address: ______________________________________________________( Street and / or PO Box)

City: __________________________________ State: ______ Zip: _____________

Phone: ____________________________ Fax: _____________________________

Tax Exemption # (Sales Tax #): ____________________

Shipping Address (If different from above address): __________________________________________(Street and / or PO Box)

City: __________________________________ State: _______________ Zip: ___________________

Authorized Signature: _______________________________________________ Date:____________________________

Referred by: _________________________________________________________

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