New Vendor Registration Form

New Vendor Registration Form
JOIN UWP NETWORK! Ultimate Wellness Providers Co. would like to add you in our network for sample collection of our innovative lab tests and services. UWP requires an initial consultation to gather information on you and your business before submitting the process to get you started with our group. Offering our UWP Lab Service and its partnered clients at your location and/or mobile will attract new customers who are proactive about their health, enthused about disease prevention, and open to self-pay. UWP is open to discussing cooperative models and systems with your establishment once you become a member of our UWP Networking Group. We will schedule a call for you to answer any other questions we may have and discuss how we can help you grow your business and customer base.

To proceed, please submit your request and registration fee. We will contact you to finalize the process.
SECTION 1. VENDOR INFORMATION
Vendor Entity Name/Legal Name*
Type N/A if this does not apply to you
State of Organization*
Type N/A if this does not apply to you
OR Which state you plan to open your business?
Principal Place of Business*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shipping Address (if the same as your place of business, you may skip)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Remittance Address: (If different from address per W9 form)
SECTION 2. Contact Information

The information must belong to authorized contact person of the entity.
Owner of Business Name*

First NameLast Name
Form filled out by: *

First NameLast Name
Title:*
Email*
example@example.com
Your Business Website*
https://example.com
Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Vendor Fax:

Area CodePhone Number
Limited Liability Company -LLC (EIN/TIN Required)*Partnership (EIN/TIN Required)*Corporation (EIN/TIN Required)**ProprietorshipTrustEmployee/Candidate Reimbursement/ Government Agencies/ Non-Profit OrganizationsNONEOther
TIN/ EIN: *
SECTION 3.
How did you hear about us?
Description of Service
Best time/day to reach you:*
How many employees do you have:*
How many contractors do you have:*
Online Portals you or your business currently use:*
CENTRIFUGENEEDLESHUBSTURNIQUETSLAB TUBES ON HANDIV THERAPY SUPPLIESOffice furnitureOther Lab SuppliesNONEDoes not apply to youOther
YESNO
Desired Business Location:
Select Investment Range
How soon you looking to make a decision?
SECTION 4. FORMS:
W9 FORM

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BUSINESS ENTITY FORMS: SECRETARY OF STATE

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Required Cancelof
CERTIFICATIONS

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Upload your certifications Cancelof
CERTIFICATIONS

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MALPRACTICE/ LIABILITY INSURANCE

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*Most of our high profile clients will require you to have. Cancelof
CLIA CERTIFICATION

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By emailBy phoneUWP PortalALL
VENDOR HEREBY CERTIFIES THAT IT IS NOT CURRENTLY EXCLUDED OR INELIGIBLE TO PARTICIPATE IN ANY FEDERAL OR STATE HEALTH CARE PROGRAMS, AND THAT IT WILL PROMPTLY NOTIFY UWP AND UPDATE THIS CERTIFICATION IN WRITTING WITHIN THIRTY (30) DAYS SHOULD IT BECOME EXCLUDED OR INELIGIBLE: *

Clear
Name*

First NameLast Name
Title:*
Date*

MonthDayYear
Date
Type letters shown below*
By checking this box, I agree the Registration Fee is non-refundable. Once payment is complete, there will be no refunds. In the event of emergency circumstances a credit for future use may be granted on the case by case bases with the approval of upper management only. All fraudulent chargebacks will be prosecuted to the full extent of the law in addition to seeking full criminal charges. All claims and disputes arising under or relating to this agreement are to be settled by binding arbitration in the location chosen by the seller. In the event that a party fails to pay any award, the award may be converted to judgment in a court of competent jurisdiction.
Credit Card Payment Authorization

I authorize Ultimate Wellness Providers Co. to charge my credit card as indicated above for payment of goods and
services, for the amount specified only, and this authorization is valid for one time use only.
I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit
card company; as long as the transaction corresponds to the terms outlined above.
Name

First NameLast Name
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature*

Clear

REGISTRATION FEE:*

Vendor Registration Fee:$125.00

Vender Registration Fee

Quantity
Item subtotal:$0.00

Subtotal $0.00Tax $0.00Total $0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Should be Empty:

New Vendor Registration Form

SECTION 1. VENDOR INFORMATION

SECTION 2. Contact Information

SECTION 3.

SECTION 4. FORMS:

Payment Methods