Trade Registration

Thanks for you interest in selling PITT BALM™ in your store. In order to get started, please complete this form so we can get you set up on our systems.

If you’ve not already emailed your initial order to us, feel free to use the notes section at the bottom of this form and one of our sales reps will get back to you.

    Company Details

    Primary Contact

    Secondary Contact

    Shipping Address

    Billing Address

    (If different from shipping address)

    Agreed payment terms:
    (Credit is approved on a case by case basis. If you would like to request special payment terms please discuss this with your account manager)