Wholesale Login or Register

Register for Wholesale

Thank you for your interest in opening an account with Liberate Yourself. Liberate Yourself is the wholesaler of the hCG weight loss program.

To gain a better understanding of the nature of your business, where you are located and how we can best serve your needs, please complete the form below. A member of our team will contact you directly to proceed with your application.

All fields are required. You must enter a valid ABN.
Company Information
Company/Business Trading Name*
Nature of business
ABN/ACN*
Date business commenced trading*
Date Format: DD slash MM slash YYYY
Telephone number*
Email*
Website*
Nominated Contact
First Name*
Last Name*
Accounts Payable Contact
(if different from above)
First Name
Last Name
Street Address
Retail Street Address*
City*
State*
Post Code*
Country*
Delivery Address
Delivery Address*
City*
State*
Post Code*
Country*
Messages
How did you hear of us?
Specific Requests
Would you like to receive the occasional email relevant to hCG support and information pertinent to assisting your clients/customers? (your email will remain confidential)
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.