Wholesale Account Agreement

Business Name/DBA:*

Tax ID #:*

First Name:*

Last Name:*

Owner Name:*

Email:*

Address:*

City:*

State:*

Zip:*

Phone:*

Fax:

Do you want approval to sell Blackboard through the internet?
YesNo

Would you like to be listed in the Blackboard locator service on our website?
YesNo

Website URL:

Years in business:*

Business Type:

Shipping Address (If different from above)

Street:

City:

State:

Zip:

Do you sell other orthotic products?
YesNo

Do you would like to get videos and publicity to actively promote the BlackBoard.
YesNo

I noted that the recommended Minimum Advertised Price of the BlackBoard is 89,- Euro*
I agree that the minimum commercial order is 10 pices.*
I have read and agreed to the Terms and Conditions.*
I agree with the privacy policy.*

Spam protection: What is seven minus three? (Please enter number)