New Customer Set-Up Form

Thank you for your interest in becoming a reseller of JoViPak products. To submit your application please complete the information requested below and someone will contact you from the JoViPak team.

Company information

* Full legal business name

* Company name for reseller listing

* Contact name for reseller listing

UPS # for third party shipping

* Address

* City

* State

* Zip code

* Phone



Shipping information

Same as Above

Business name







Billing information

* Billing contact name

* Billing phone

Billing fax

Email for invoicing and statements

* State Resale # or Taxpayer ID# (If International use 0000)

Invoice/Statement Notification Preference

Payment Options



  • Terms are Net 30 Days and paid in US Dollars.
  • All orders are subject to acceptance by JoViPak.
  • Appliant acknowledges liability for payment of amounts due to JoViPak for products received. All overdue amounts are subject to a late fee of 1% per month (12% per annum) from the date due. Any account not within terms will not have new orders processed until the account is brought current.
  • Prices, discounts and terms may change without notice.
  • All accounts and products are subject to JoViPak policies regarding guarantee, warranty, and return. Refer to Warranty, Alterations and Returns for more information.
  • Custom garments: If a garment does not fit the patient at the initial fitting, new measurements must be taken for comparison and to honor the Guarantee to Fit Policy. 
  • Alterations: If a garment is being returned for alteration, the garment MUST BE CLEAN per FDA regulations. If any garment requires cleaning prior to alteration, a $25.00 laundry fee per item will be applied. Refer to alteration instructions on pages 3 & 4 of the Product Guide.

By signing below on behalf of your business, you represent that your business is a valid entity; that all purchases made on this account will be for the purposes other than personal, family or household use; and that you are an authorized representative of the business with authority to enter into contractual agreements. On behalf of the business, you certify that all information provided is complete and accurate.

* I am the following Authorized Representative of the business

* Full name of the Authorized Representative of the business

* Date

* I have read and agree with the Terms and Conditions.


Thank you for your submission. JoViPak will review and a representative will be getting a hold of you.