Wholesale Application Form - Business Entity Accounts
Account Registration - Business Entity Account
Business Entity
*
Business Entity Name:
Practice Name/DBA of Business Entity (If different)
Business Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Copy of Resale Tax License/Certificate (*Required if no license, optional for licensed)
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Please list ALL qualified healthcare practitioners listed under the Business Entity that will be using this account
*
Practitioner First Name
Practitioner Last Name
Practitioner Phone Number
*
Practitioner Email Address
*
Practitioner License #
*
Practitioner License #
Practitioner Specialty
*
Please Select
MD
Licensed ND
PA-C
LAc
NP/APRN
DC
DVM
DO
PharmD
Licensed DOM
DDS
Other
***If “Other” is selected, please reach out to contact@alighthealthformulas.com for further instructions
Copy of Practitioners License/Certificate
*
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If "Other", please specify license type:
Practitioner 2:
Practitioner First Name
Practitioner Last Name
Practitioner Phone Number
Practitioner Email Address
Practitioner License #
Practitioner License #
Practitioner Specialty
Please Select
MD
Licensed ND
PA-C
LAc
NP/APRN
DC
DVM
DO
PharmD
Licensed DOM
DDS
Other
***If “Other” is selected, please reach out to contact@alighthealthformulas.com for further instructions
Copy of Practitioners License/Certificate
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If "Other", please specify license type:
Practitioner 3:
Practitioner First Name
Practitioner Last Name
Practitioner Phone Number
Practitioner Email Address
Practitioner License #
Practitioner License #
Practitioner Specialty
Please Select
MD
Licensed ND
PA-C
LAc
NP/APRN
DC
DVM
DO
PharmD
Licensed DOM
DDS
Other
***If “Other” is selected, please reach out to contact@alighthealthformulas.com for further instructions
Copy of Practitioners License/Certificate
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Choose a file
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of
If "Other", please specify license type:
Practitioner 4:
Practitioner First Name
Practitioner Last Name
Practitioner Phone Number
Practitioner Email Address
Practitioner License #
Practitioner License #
Practitioner Specialty
Please Select
MD
Licensed ND
PA-C
LAc
NP/APRN
DC
DVM
DO
PharmD
Licensed DOM
DDS
Other
***If “Other” is selected, please reach out to contact@alighthealthformulas.com for further instructions
Copy of Practitioners License/Certificate
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If "Other", please specify license type:
Acknowledgements:
*
We understand that in order to carry the Alight Health Formulas brand, qualified healthcare practitioners are required to hold current, active, and non-restricted licenses to practice, and that Alight Health Inc has a right to request proof of licensure for any qualified healthcare practitioner at any time while we carry the products.
We agree to abide by Alight Health Formulas’ policy on internet sales, in that in no event shall we, or any individual practitioner at our company, 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 Business Entity Terms below.
Wholesale Business Entity Terms
Privacy Policy
Terms Of Use
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