Apply for a Wholesale B2B Account

Use this form to apply for a wholesale account. After a brief approval period, you will be sent an email to finish your account creation.

Customer Information

First Name Required

Last Name Required

Email Required

Address 1 Required Address 2 Required

City

Country Required

State/Province

Zip/Postal Code

Website* Required

Phone Number* Required

Tax ID/ABN/VAT Number* Required

Note Required

Marketing Opt In

Company Name* Required

Legal Company Name* Required

Annual Revenue* Required

Dun & Bradstreet # Required

Net Payment Terms

How did you hear about 4XEM?* Required

Please upload a copy of your W9*

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4XEM Newsletters

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