new_distributor

New Distributor Form

*Required

Distributor Information

Referring Distributor ID Number

This 4 or 5 digit number can be found at the top of the warranty card on the inside of your insole package, written on the marketing materials you received from a Distributor, or on the website you are visiting. If you do not have one leave this field blank.

*Name

Business Name

*Street Address

Street Address 2

*City

*State or Province

*Country

*Zip Code or Country Code

*Phone Number

*Email

*Confirm Email

*Where Did You First See Foot Relief Insoles or Related Products?

This question helps us determine which Distributor will get credit for referring you.

Questions or Comments

Distributor Eligibility Verification

*Are You a Resident or Business in the State of California? Select one:

Yes - I am a Resident or Business in the State of California and Insoles will be resold in CA. (Please enter your Seller's Permit number below after checking this box) No - I am not a Resident or Business in the State of California and Insoles will not be resold in CA. (Your state may require you to have a seller's permit.) Skip to Resale Certificate Statement of Eligibility.

If You Will be Purchasing Insoles to be Resold in the State of California, Enter Your CA Reseller Number Here:

California Resellers: We are required to collect your Reseller Number before we can sell you merchandise wholesale for resale. Filling out this form and furnishing a California Reseller Number to purchase merchandise for personal use that will not be resold in order to avoid paying sales tax is against the law. Selling merchandise in the State of California without a valid seller's permit number is also against the law.

Resale Certificate Statement of Eligibility - Read Before Submitting this Form

*Resale Certificate Statement of Eligibility Acknowledgement:

I Have Read and Agree to the Resale Certificate Statement of Eligibility

You Must Agree to the Resale Certificate Statement of Eligibility by Checking the Button Above. Otherwise do not submit this form.

Distributor Agreement and Terms of Service Verification

Click Here to Open the Distributor Agreement and Terms of Service in a New Window

*Distributor Agreement and Terms of Service Acknowledgement:

I Have Read and Agree to the Distributor Agreement and Terms of Service

You Must Agree to the Distributor Agreement and Terms of Service by Checking the Button Above. Otherwise do not submit this form.