Wholesale App

Wholesale Registration Application

Please fill out this form to sign up for our wholesale Program and receive large price reductions

Company or Facility *

If you are a caregiver, please type your name

Phone Number *

Address

First name

Last name *

Company

Shipping address *

Apartment, suite, etc. (optional)

City *

Country/Region *

Province/State/Region *

Postal code *

Email *

Accept to receive notifications by email.

Do you plan to purchase in bulk or dropship direct to your customers? *

What Type of Business/Account Are You? *

What Categories Are You Interested In Purchasing? *

Check all that apply

Mobility Products

Beds & Recliners

Personal Protection Equipment

Dentures and Oral Care

Wound Care

Incontinence

Patient Lifts and Transfer Equipment

Other

If you are Tax Exempt, Please attach your tax exempt certificate here:

The max file size is 50MB.

Please upload a file before submitting.

State Tax Certificate Number

Are there any specific products you are looking for and how often do you plan to purchase from Senior.com? *

Any additional information that will help us qualify you? *

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Order products

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Order Total (The sum of all the prices of all the items in the order, taxes and discounts included.)

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Contact information

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Billing address

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