Wholesale Application Form Please fill out this form if you are interested in being a wholesale seller of Synergy by Shira Adler "*" indicates required fields Today's Date* MM slash DD slash YYYY First Name* Last Name* Primary Email Address* Do you have another email address? Yes No Other Email Address Primary Phone Number*Do you have another phone number? Yes No Other Phone NumberCompany Name* Tax ID* Company Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is your company address the same as your delivery address?* Yes No What type of company do you have?*Sole ProprietorLLCCorporation (Subchapter S)Corporation (C)Non-ProfitOtherOther type of company?* Do you carry other CBD-based products?* Yes No What products do you want to carry?* Shira Synergy Sprays, Individual Shira Synergy Sprays, Set CBD Tinctures Bliss Butter ABCs of CBD Book All Other For our tinctures: as we are in process of expanding our manufacturing capabilities, we have temporarily paused the re-release of our tinctures. If you wish to carry our full spectrum hemp derived tinctures in 750mg, 1500mg, or 3000mg strength, please let us know. We anticipate returning tinctures to our wholesale offerings in Summer 2024 and are excited to be preparing for the launch of our new Synergy Sensuals duo combo (Bliss Butter, Sensual Spray...and coming soon: our sensual lubricant).If other products, please explain*Please upload your Reseller Certificate*Max. file size: 100 MB.Please upload a completed copy of your reseller certificate for us to keep on file.Do you want Shira or a staff member to do a presentation for your staff or purchasers?*This can be done in person or Zoom. Yes No Maybe Terms & Conditions- Payment is due before we ship products unless other arrangements are made prior to placing an order. - Minimum quantities (MOQ) apply. - We have flexible MOQs, starting with a 1-case minimum, based on size of business, - Payments may be made through Venom, PayPal, or CashApp. - Credit card orders include a 4% processing fee in addition to the standard pricing, sales tax, and shipping charges. Fee is waived for wholesalers who have submitted a resale certificate through the website - Wholesalers may use their discretion to offer products at, or higher than MSRP, as well as lower for sales/specials/pre-launch prices for new products/lines including: the about to launch Synergy Sensuals. - All POs require a 50% non-refundable deposit at time of order, and the remainder prior to shipping. Returns will be paid for by customer, and are subject to a 20% restocking fee for unopened merchandise. Due to federal regulations, we are only able to accept unopened merchandise as they are manufactured by a cGMP facility (see policies page on website). - We are planning to be able to offer lower pricing with our new manufacturer. As such, Synergy by Shira Adler may, at its discretion, lower current MSRP, and if so, independent retailers/wholesalers may choose to lower, or maintain current MSRP at their discretion. - Requests may be made for special arrangements, MOQs, terms (for existing wholesalers/retailers), and distribution or white label pricing and agreements by contacting: SynergybyShira@gmail.comBy agreeing to this form constitutes agreement with the Terms & Conditions* I agree to the Terms & ConditionsCAPTCHAEmailThis field is for validation purposes and should be left unchanged. 62015 Let’s Be Social FollowFollowFollowFollowFollow
