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)