Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

[this is used for security verification if required]

MM

DD

YYYY

I would like to receive Wholesale Customer benefits, which includes 25% Discount on Products, for an annual rate of $42 CDN. *

Membership also includes: Earns Loyalty Rewards Program Points, Earns Shipping Rewards Points, Can Qualify for Free Product of the Month, Receives a Free Bottle of Peppermint Essential Oil with Membership Renewal [***Please note the $42 is waived when you purchase an enrollment kit].

Yes, please add the Wholesale Customer Membership.

No, thank you, I will pay retail pricing.

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping Address [if different than billing address]

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name on credit card *

First Name

Last Name

Expiry Date *

MM

DD

YYYY

Would you like me to text you with a screenshot of the total before I process it? *

Yes

No