{practice_name} Owner Affirmation and Signature

The section below is to be duly completed by {owner_name}, the owner, managing director or authorized representative of {practice_name}

I, {owner_name}, in my capacity as the owner or authorized representative of {practice_name}, hereby declare that all the information provided in this application form for becoming a Dermal Health Dispensing Practice is complete, true, and accurate to the best of my knowledge.

I affirm that {practitioner_name}, is permanently affiliated with {practice_name} as a {pactitioner_profession} and that the practice complies with all the requirements set forth by Dermal Health Science for becoming a stockist. I understand that providing false or incomplete information may result in the immediate termination of any agreement reached and could incur legal consequences.

By signing below, I acknowledge that I have read, understood, and agree to the terms and conditions set forth by Dermal Health Science regarding the stocking and dispensing of its products.

Signed by: {owner_name}

{owner_profession} | {practice_name}

Date: {date_submit}

{pactitioner_profession}'s Affirmation and Signature

The section below is to be duly completed by {practitioner_name}, the {pactitioner_profession} who is permanently affiliated with your practice.

I, {practitioner_name} in my professional capacity as {pactitioner_profession}, hereby affirm my permanent affiliation with {practice_name}. I take responsibility for ensuring the appropriate use and dispensing of DermExcel and other Dermal Health Science products at the said practice.

I confirm that all the information provided in this application form, particularly concerning my professional credentials and the practice's details, is complete, accurate, and true to the best of my knowledge. I understand that providing false, incomplete, or misleading information may immediately terminate the practice's status as a Dermal Health Dispensing Practice and could subject me to legal consequences.

By signing below, I declare that I have read, understood, and agree to uphold the terms and conditions set forth by Dermal Health Science, particularly those concerning the responsible stocking and dispensing of its medical-grade aesthetic dermatology products.

Signed by: {practitioner_name}

{regulated_body} Reg. No: {registration_number}

Date: {date_submit}

I, {owner_name} in my dual capacity as {pactitioner_profession} and the owner, affirm my ownership and medical oversight of {practice_name}. I am responsible for appropriately utilizing and retailing DermExcel and other Dermal Health Science products within this practice.

I hereby certify that all information supplied in this application, especially concerning my professional credentials and the particulars of the practice, is complete, accurate, and truthful to the best of my knowledge and belief.

I comprehend that furnishing false, incomplete, or misleading information could result in the immediate revocation of the practice's status as a Dermal Health Dispensing Practice and may expose me to legal ramifications.

By affixing my signature below, I attest that I have thoroughly read, understood, and agree to comply with the terms and conditions set forth by Dermal Health Science, particularly concerning responsible stocking and dispensing of its advanced medical-grade aesthetic dermatology products.

Signed by: {owner_name}

{regulated_body} Reg. No: {registration_number}

Date: {date_submit}