Millennium Form


New Account Sign Up
fiogf49gjkf0d New Wholesalers/Distributors To place an order, you need to establish an account with MillenniumDirectSM. To establish an account please download, print and complete the Business Application. Forward the completed application via fax or mail with a copy of the appropriate license. We must have a signature on the application form and appropriate license information for each ship-to location before product can be shipped. Once you have established an account with MillenniumDirect, you may then sign-up for a web account to begin ordering online. Business Application (Adobe PDF) New Ship To To add a new Ship To location to your account, please complete the "New Ship To" form. Forward the completed form via fax (877.878.3479) or mail with a copy of the location's state license. You will be notified upon setup of the new location via telephone and/or email. Processing time is 24 hours before New Ship To will be available for order placement. New Ship To Form (Adobe PDF) Existing MillenniumDirect Customers If you currently have an established account with MillenniumDirect and would like to begin purchasing products online, please fill out the form below and click submit when complete. Web order access will be made available to existing customers within 24 hours of receiving the request.
Fields marked with * are required.
MillenniumDirect Account # *	Your account number, without the preceding zeros, will be your login ID
Company Name *
Address *
City *
State *
Zip *
Phone *
Email *
First Name *
Last Name *
Password *	Your Password must be at least 6 characters in length and will be required each time you log into the site. This password should be a combination of letters and numbers that only has significance to you. Password must have at least one numeric value.
Password Question *	If you forget your password, the question you have entered above will be used to verify your identity.
Password Answer *
Comments