Reseller Application

Full Name*

Email Address*

Date of Birth*

Country*

State*

City*

Zip / Postal Code

Mobile / Phone Number*

Do you have Bitcoins Wallet ?*
YesNoNo, But i will get one

Do you have any experience with selling of prescription drugs?*
YesNo

Do you want to re-sell all products we are offering or some specific products?*
AllSpecific

Additional message (optional)