Company Name *

First Name *

Last Name *

Email *

Phone *

Fax (optional)

Cell (optional)

Country *United StatesPuerto RicoCanada

Address 1 *

Address Line 2 (optional)

City *

State *

Postcode *

Date Business Commenced: *

Choose Business Type *Choose oneCorporationlimited liability corp / LLCPartnershipSole ProprietorOther

Choose how will you be selling MyND Products *Choose OneOnline StorePhysical StoreBoth

SSN or EIN (numbers only) *

Username *

Password *

Confirm password

Please upload your Reseller Certificate

Please upload your Drivers License *

Please upload your Business License