ACCOUNT APPLICATION

For wholesale buyers only. Fill out once. Your billing and shipping information will be saved for all future orders. We never share your information, ever. This is a secure site. Order immediately.

Business Name *

Contact First Name *

Contact Last Name *

Shipping Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Billing Address (Leave blank if same as shipping address)

Address Line 2

City

State

Zip Code

Bank Name *

Bank Phone *

Tax ID Number *

Preferred Method of Payment *

Please use the Business Name, Address and Phone Number above as contact information under 'Where to Buy', on the Pure Elixir website. *

Yes

No

We advertise for you!
Please use this information on the Pure Elixir website under 'Where to Buy':

Where did you hear about us?

Thank You! You may now proceed to the order form and place an order.