Wholesale Application Form

Wholesale Form

Thank you for your interest in BrothRX wholesale!

Please complete the questions below and one of our team members will be in contact as soon as possible.

Questions? Email us at: info@broth-rx.com

Business Name*

Contact Person Name*

Contact Person Title*

Contact Person E-Mail*

Business Phone*

Business Website*

Business Address*

Second line of address

ZIP code



Briefly Explain Your Business*

How will you sell Broth RX Products?*

If other, please explain

What is your primary business focus?*

If your primary business focus is as Physical Store, which of the below best describes your business?
(Please choose the following from the descriptions below)*:

Does your physical store have more than one location?*

How many stores do you have?*

Where are your company headquarters?

HQ address line one

Second line of address

ZIP code



How did you hear about our wholesale program?*

If 'Broker' selected, who?