Purify Your Body offers detox foot pads at wholesale pricing to health related clinics, practitioners, and stores. To qualify for this pricing a Tax ID number is required. To register as a wholesaler, please fill out the information below and a choose a username and password. This will enable you to place discounted-price orders via the web. You will still be able to place orders directly with me via the phone or via email if you want to skip this step.

Items appearing in bold are required.

First Name:
Last Name:
Username:
Password:
Password Confirmation:
Email Address:
Email Address Confirmation:
Company:
Mailing Address:
Mailing Address 2:
City:
State:
Zip Code:
Home Phone Number:
Work Phone Number:
Cell Phone Number:
Alternate Email Address:
Please add me to the Purify Your Body mailing list:
I have read and agree to the Purify Your Body membership agreement:
Tax ID# (FEIN)
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