Reseller Application Form

Fields marked with * are required

Contact Information

* Name (First and Last)

* Email Address

Business Information

* Business Name

* Business Address

Suite

* City

* Country

* Province

* Postal Code

* Business Phone

Mobile Phone Number

Fax

* Website Address

Order Information

Order Type

PharmacyNaturalMedical OfficeOther

If you selected other, please specify:

* Initial order volume (product, # of unit):

* Anticipated annual order volume (product, # of unit):

* Purchased product(s) will be sold: In storeDomestic online (ex. Amazon)International onlineOther

If other (please specify):

* Please select distribution region

If other (please specify):

Thank you for your interest in Ddrops products. Be sure to fully complete the above application with as much information as possible. Only approved resellers are eligible to place an order. Due to the volume of applications, we will contact only successful applicants.

Please note that all orders must be pre-paid and delivery is within Canada or the US.

If a distributor or reseller chooses to export Ddrops^® products beyond North America, the distributor assumes all responsibility for the product and medical related inquires. For export purpose, US labeled Ddrops^® products are the only format available. Ddrops Company does not prepare nor provide input to export paperwork. Distributors or resellers will be obligated to indemnify the Ddrops Company with respect to any claims arising after resale.

Ddrops Company does not currently have exclusive agreements with any resellers. Ddrops Company pricing is as per the current Ddrops^® catalog. This information is confidential and subject to change without notice.

I consent to privacy terms

* I AGREE, I have read and agree to the privacy policy and terms on the Ddrops website prior to submitting this sample request form.