Application Form - Wholesale/Practitioners

Application Form - Wholesale/Practitioners

Account Registration - Individual Practitioner Account
Practitioner Registration*

Practitioner/Owner First NamePractitioner/Owner Last Name
Practice Name:*
Practitioner Email Address*
example@example.com
Practitioner Phone Number:*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please tell us about your practice
Practitioner License/Certificate #:*
Practitioner Specialty *
If you selected “Other”, please specify license/certificate type:
Copy of Practitioners License/Certificate*

Cancelof
Copy of Resale Tax License/Certificate

(*Required if no license, optional for licensed)
Cancelof
Acknowledgement:*

I understand that in order to carry the Alight Health Formulas brand, I am required to hold a current, active, and non-restricted license to practice, and that Alight Health Inc has a right to request proof of licensure at any time while I’m carrying the products.I agree to abide by Alight Health Formulas’ policy on internet sales, in that in no event shall I sell any Alight Health Formulas products through any third-party seller, such as Amazon or eBay.By entering my information and using the site, I agree to the Privacy Notice and Terms of Use.By checking this box I acknowledge that I have read and agree with the Wholesale Practitioner Terms below.
Privacy Policy
Terms Of Use
Should be Empty:

Please tell us about your practice