Thank you for your interest in becoming a Lemongrass® reseller. All resellers must be approved prior to receiving wholesale pricing. Please fill out this form completely and fax your Resellers Certificate to (954)418-6177. Upon approval, you will be emailed a Login ID.
BUSINESS NAME:
BUSINESS TYPE:
TAX ID#:
YEARS IN BUSINESS:
ADDRESS 1:
ADDRESS 2:
CITY:
STATE:
ZIP:
OWNERS FIRST NAME:
OWNERS LAST NAME:
BUYERS FIRST NAME:
BUYERS LAST NAME:
BUSINESS PHONE:
BUSINESS FAX:
CELL PHONE (optional):
EMAIL:
ENTER A PASSWORD: