Wholesaler/Distributor Application Form

If you are interested in becoming a vendor of Ohm Therapeutics, please fill
out the form below and we'll contact you regarding setting up an account. Thank you.

Name:
Email Address:
Web Address:
Phone:
Fax:
Address:
City:
State/Provence:
Zip/Postal Code:
Country:
Business Name:
Business Type:
Retail Outlet?: Yes
No
How long have you been in business?:
Name of Owner(s):
Main Contact:
Your Payment Reference:
Please describe the nature of your business:
Your questions/comments: