Wholesale Account Application Form

To establish a wholesale account with us and access our website at www.wholesale.healthmobius.com, you will need to follow the instructions below:

  1. Register your account via the My Account page
  2. Complete the forms below. Please note you MUST provide the User ID (log in name) you created on our website as well as all websites you will be selling on.

We will quickly process your application and contact you when your account has been reviewed. For assistance with filling out the application, feel free to call us at 630-325-5150.


I agree to comply with the Health Mobius Policies and Website terms and conditions as updated from time to time, including but not limited to:

  1. Following Minimum Advertised Price (MAP), when it exists.
  2. Identifying, disclosing and requesting permission to resell products purchased through Health Mobius. This shall include requesting & obtaining express permission for each and every website and identifying all user names, DBA, telephone numbers and addresses related to ny seller account or website related to you.
  3. Not listing products on any marketplace without written permission from Health Mobius. See “Policy for Resellers” on the website f or more details.

List all Websites and all channels you sell on including your DBA & Seller Name on each channel:


The below-listed states have indicated that this form of certificate is acceptable, subject to the notes on 2-4. The issuer and the recipient have the responsibility of determining the proper use of this certificate under applicable laws in each state, as these may change from time to time.

Issued to Seller:

Health Mobius LLC, 260 Shore Ct, Burr Ridge, IL 60527

is engaged as a registered:

and is registered with the below listed states and cities within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, ingredients or components of a new product or services to be resold, leased, or rented, in the normal course of business. We are in the business of wholesaling, retailing, manufacturing, leasing (renting) the following:

Find your state below. If blank, enter your State Registration, Seller's Permit, or ID Number. If not, follow your state's instructions.

State State Registration, Seller's Permit or ID Number of Purchaser State State Registration, Seller's Permit or ID Number of Purchaser
AK Provide EIN# below MT Provide EIN# below
CO This form does not apply. Use Colorado State Form DR-0536 NJ
DE NY This form does not apply. Use Colorado State Form ST-0120

For buyers with location in states that do not require state tax registration, please check the appropriate box(es) and supply your federal EIN#

I further certify that if any property of service so purchased tax free is used or consumed by the firm as to make it subject to a sales or use tax, we will pay the tax due directly to the proper taxing authority when state law so provides or inform the seller or added tax billing. This certificate shall be a part of each order which we may here after give to you, unless otherwise specified, and shall be valid until canceled by us in writing or revoked by the city or state. Under penalties of perjury, I swear or affirm that the informatinon on this form is true and correct as to every material matter.

Owner Partner Or Corparate Officer


To Seller's Customers:

In order to comply with the majority of state and local sales tax law requirments, the seller must have in its files a properly executed exemption certificate from all of its customers claim a sale tax exemption. if the seller does not have this certificate, it is obliged to collect the tax for the state in which the property of service is delivered.

If the buyer is entitled to sales tax exemption, the buyer should complete the certificate and send it to the seller at its earliest convenience. If the buyer purchases tax free for a reason for which this form does not provide, the buyer should send the seller its special certificate or statement.

Caution to Seller:

In order for the certificate to be accepted in good faith by the seller, seller must exercise care that the property or service being sold is of a type normally sold wholesale, resold, leased, rented or incorporated as a ingredient or component part of a product manufactured by buyer and then resold in the usual course of its business. A seller failing to exercise due care could be held liable for the sales tax due in some states or cities. Misuse of this certificate by seller, lessee, or the representative thereof may be punishable by fine, imprisonment or loss of right to issue certificate in some states or cities.

  1. Alabama: Each retailer shall be responsible for determining the validity of a purchaser's claim for exemption.
  2. Arizona: This certificate may be used only when making purchases of tangible personal property for resale in the ordinary course of business, and not for any other statutory deduction or exemption. It is valid as a resale certificate only if it contains the purchaser's name, address, signature, and Arizona transaction privilege tax (or other state sale tax) license number, as required by Arizona Revised Statutes § 42-5022, Burden of proving sales not at retail.
  3. California:
    1. This certificate is not valid as an exemption certificate. Its use in limited to use as a resale certificate subject to the provisions of Title 18, California Code of Regulations, Section 1668 (Sale and Use Tax Regulation 1668, Resale Certificate).
    2. By use of this certificate, the purchaser certifies that the property is purchased for resale in the regulation course of business in the form of tangible personal property, which includes property incorporated as an ingredient or component part of an item manufactured for resale in the regular course of business.
    3. When the applicable tax would be sales tax, it is the seller who owes that tax unless the seller takes a timely and valid resale certificate in good faith.
    4. A valid resale certificate id effective until the issuer revokes the certificate.
  4. The state of Colorado, Hawaii, illinois, and New Mexico do not permit the use of this certificate to claim a resale exemption for the purchase of a taxable service for resale.
  5. Connecticut: This certificate is not valid as an exemption certificate. Its use in limited to use as a resale certificate subject to the Conn. Gen. State §§12-410(5) and 12-411(14) and and reglulations and administrative pronouncements pertaining to resale certificate.
  6. District of Columbia: This certificate is not valid as an exemption certificate. It is not valid as a resale certificate unless it contain the purchaser's D.C. sales and use tax registration number.
  7. Florida: The Department will allow purchasers to use the Multistate Tax Commission's Uniform Sales and Use Tax Certificate-Multi Jurisdicition. However, the use of this uniform certificate must be used in conjunction with the telephonic or electronic authorization number method described in paragraph (3)(b) or (c) of rule SUT FAC 12A-1.039.
  8. Georgia: the purchaser's state of registration number will be accepted in lieu of Georigia's registration number when the purchaser is located outside Georgia, does not have nexus with Georgia, and the tangible personal property is delivered by drop shipment to the purchaser's customers located in Georgia.
  9. Hawaii allows this certificate to be used by the seller to claim a lower general excise tax rate or no general excise tax, rather than the buyer claiming an exemption. The no tax situation occurs when the purchaser of imported goods certifies to the seller, who originally imported the goods into Hawaii, that the purchaser will resell the imported goods at wholsale. if the lower rate or no tax does not in fact apply to the sale, the purchaser is liable to pay the seller the additional tax imposed. See Hawaii Dept. of Taxation Tax Information Release No. 93-5, November 10, 1993, and Tax Information Release No. 98-8, October 30, 1998.
  10. Use of this certificate in Illinois is subject to the provision of 86 Ill. Adm. Code Ch.I, Sec. 130.1405. Illinois does not have an exemption on sales of property for subsequent ease or rental, nor does the use of this certificate for claiming resale purchase of services have any application in Illinois.

    The registration number to be supplied next to illinois on page 1 of this certificate must be the Illinois registration or resale number;no other state's registration number is acceptable.

    "Good faith" is not the standard of care to be exercised by a retailer in Illnois. A retailer in Illnois is not required to determine if the purchaser actully intends to resell the item. Instead, a retailer must confirm that the purchaser has a valid registration or resale number at the time of purchase. If a purchaser fails to provide a certificate of resale at the time of sale in illnois, the seller must charge the purchaser tax.

    while there is no statutory requirment that blanket certificates of resale be renewed at certain intervals, blanket certificate should be updated periodically, and no less frequently than every three years.

  11. Kentucky:
    1. Kentucky does not permit the use of this certificate to claim a resale exclusion for the purchase of a taxable service.
    2. This certificate is not a valid as an exemption certificate. Its use is limited to use as a resale certificate subject to the provisions of Kentucky Revised Statute 139.270 (Good Faith).
    3. The use of this certificate by the purchaser constitutes the issuance of a blanket cerficate in accordance with Kentucky Administrative Regulation 103 KAR 31:111.
  12. Maine does not have an exemption on sales of property for subsequent lease or rental.
  13. Maryland: This certificate is not valid as an exemption certificate. However, vendors may accept resale certificates that bear the exemption number issued to a religious organization. Exemption certifications issued to religious organizations consist of 8 digits, the first two of which are always "29". Maryland registration, exemption and direct pay numbers may be verified on the website of the Comptroller of the Treasury at www.marylandtaxes.com.
  14. Michigan: Effective for a period of four years unless a lesser period is mutually agreed to and stated on this certificate. Covers all exempt transfer when accepted by the seller in "good faith" as defined by Michigan statute.
  15. Minnesota: A. Does not allow a resale certificate for purchases of taxable services for resale in most situations. B. Allow an exemption for items used only once during production and not used again.
  16. Missouri:
    1. Purchases who improperly purchase property or services sales tax free using this certificate may be required by pay the tax, interest, additions to tax or penalty.
    2. Even if property is delivered outside Missouri, facts and circumstances may subject it to Missouri tax, contrary to the second sentence of the first paragraph of the above instructions.
  17. Nebraska: A blanket certificate is valid 3 years from the date of issuance.
  18. New Mexico: For transactions occurring on or after July 1, 1998, New Mexico will accept this certificate in lieu of a New Mexico nontaxable transaction certificate and as evidence of the detectability of a sale tangible personal property provided:
    1. this certificate was not issued by the State of New Mexico;
    2. the buyer is not required to be registered in New Mexico; and
    3. the buyer is purchasing tangible personal property for resale or incorporation as an ingredient or component part into a manufactured product.
  19. North Carolina: This certificate is not valid as an exemption certificate or if signed by a person such as a contractor who intends to use the property. Its Use is subject to G.S. 105-164.28 and any administrative rules or directives pertaining to resale certificates.
  20. Ohio:
    1. The buyer must specify which one of the reasons for exemption on the certificate applies. This may be done by circling or underlining the appropriate reason or writing it on the form above the state registration section. Failure to specify the exemption reason will, on audit, result in disallowance of the certificate.
    2. In order to be valid, the buyer must sign and deliver the certificate to the seller before or during the period for filling the return.
  21. Okhlahoma would allow this certificate in lieu of a copy of the purchaser's sales tax permit as one of the elements of "properly completed documents" which is one of the three requirements which must be met prior to the vendor being relieved of liability. The other tow requirements are that the vendor must have the certificate in his possession at the time the sale is made and must accept the documentation is good faith. The specific documentation required under OAC 710-:65-7-6 is:
    1. Sales tax permit information may consist of:
      1. A copy of the purchaser's sales tax permit; or
      2. In lieu of a copy of the permit, obtain the following:
        1. Sales tax permit number; and
        2. The name and address of the purchaser;
    2. A statement that the purchaser is engaged in the business of reselling the articles purchased;
    3. A statement that the article purchased are purchaed for resale;
    4. The signature of the purchaser or a person authorized to legally bind the purchaser; and
    5. Certification on the face of the invoice, bill or sales slip or on separate letter that said purchaser in engaged in reselling the articles purchased.
    Absent strict compliance with these requirments, Oklahoma holds a seller liable for sales tax due on sales where the claimed exemption is found to be invalid, for whatever reason, unless the Tax Commission determines that purchaser should be pursued for collection of the tax resulting from improper presentation of a certificate.
  22. Pennsylvania: This certificate is not valid as an exemption certificate. It is valid as a resale certificate only if it contains the purchaser's Pennsylvania Sales and Use Tax eight-digit license number, subject to the provisions of 61 PA Code §32.3.
  23. Rhode Island allows this certificate to be used to claim a resale exemption only when the item will be resold in the same form. They do not permit this certificate to be used to claim any other type of exemption.
  24. South Dakota: Service which are purchased by a service provider and delivered to a current customer in conjunction with the services contracted to be provided to the customer are claimed to be for resale. Receipts from the sale of a service for resale by the purchaser are not subject to sales tax if the purchaser furnishes a resale certificate which the seller accepts in good faith. In order for the transaction to be a sale for resale, the following conditions must be present:
    1. The service is purchased for or on behalf of a current customer;
    2. The purchaser of the service does not use the service in any manner; and
    3. The service is delivered or resold to the customer without any alteration or change.
  25. Texas: Items purchased for resale must be for resale within the geographical limits of the United States, its territories and possessions.
  26. Washington:
    1. Blanket resale certificate must be renewed at intervals not to exceed four years;
    2. This certificate may be used to document exempt sales of "chemicals to be used in processing an article to be produced for sale."
    3. Buyer acknowledges that the misuse of the tax due, in addition to the tax, interest, and any other penalties imposed by law.
  27. Wisconcin allows this certificate to be used to claim a resale exemption only. It does not permit this certificate to used to claim any other type of exemption.

Form W-9



(Rev. October 2018)
Department of the Treasury
Internal Revenue Service

Request for Taxpayer Identification Number and Certification

> Go to www.irs.gov/FormW9 for instructions and the latest informatinon.
Give Form to the requester. Do not send to the IRS.
  1. Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
  2. Business name/disregarded entity name, if different from above
  3. Check appropriate box for federal tax classification of the person whose name is entered on line 1. check only one of the following seven boxes.

    Note:Check the appropriate box in the line above for the text classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. fedral tax purpose. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

  4. Exemptions ( coded apply only to certain entities, not individuals; see instructions on page 3):

    Exempt payee code (if any)
    Exemptions from FATCA reporting code if (any)
    (applies to acccounts maintained outside the U.S.)
  5. Address (number, street, and apt. or suite no.) See instruction.
  6. City, state and ZIP code
  7. List account number(s) here (optional)
  8. Requester's name and address (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number(SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instruction for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see how to get a TIN, later.

Note:If the account is in more than one name, see the instructions for line 1. Also see What Name and Number to Give the Requester for guidelines on whose number to enter.

- -


Employer identification number

Part II Certification

Under penalties of perjury, I certify that:

  1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me):and
  2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
  3. I am a U.S. citizen or other U.S. person (defined below); and
  4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transaction, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instruction for Part II, later.

Sign here

Signature of U.S. person

General Instructions

Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instruction, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of form

An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.

  • Form 1099-INT (interest earned or paid)
  • Form 1099-DIV (dividends, including those from stocks or mutual funds)
  • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
  • Form 1099-B (stocks or mutual fund sales and certain other transactions by brokers)
  • Form 1099-S (proceeds from real estate transactions)
  • Form 1099-K (merchant card and third party network transactions)
  • Form 1098 (home mortagage interest), 1098-E (student loan interest), 1098-T (tuition)
  • Form 1099-C (canceled debt)
  • Form 1099-A (Acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a residents alien), to provide your correct TIN.

if you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.

We cannot approve the application without this step completed.