Practitioner Application

ION* Wholesale Practitioner Application
Application Information
First Name*
Last Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Modality*
Copy of Active Medical License / Certification (Upload)*

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Business Information
Company Name*
Website*
Number of Locations*
Company Phone Number*
Please enter a valid phone number.
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to be added to our store locator?*

YesNo
Is your shipping address different than your clinic address?*

YesNo
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your billing address different than your clinic address?*

YesNo
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How will you sell ION? (Select 1)*

OnlineIn your physical storeBoth
How do we find you on Social Media?
i.e. instagram handle, facebook page
Additional Information
How did you hear about ION*? (Select all that apply)

ReferralPodcastConference / TradeshowWebsiteOther
Who can we thank for your Referral?
Which podcast did you hear about ION* on?
Which tradeshow or conference did you learn about ION* at?
What website did you see ION* on?
Tell us more about how you heard about ION*!
Have you tried ION* Products yet? (Select all that apply)

ION* Gut SupportION* Skin SupportION* Gut Support for PetsI have not tried any ION* products
Upon Application approval, would you like to sign up for our Reseller Newsletter for early access to product launches, promotions, and educational material?

YesNo
Tax Exemption
Is your business tax-exempt? (This information is required to avoid paying sales tax on your ION* Orders)*

YesNo
Enter your State Registration Permit, Seller's Permit or Resale Certificate
Upload your state-issued resale or tax-exemption certificate here. For direct links to your state's documentation, please refer to State by State Exemption Certificate Guide below.

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1) If you're unsure which form to complete for your state, please refer to the this guide State by State Exemption Certificate Guide HERE for instructions and direct links to each state’s tax exemption documentation.
2) Once your application is approved, if your uploaded document is incomplete or incorrect, our accounting team will issue the correct form through Avalara (notifications@avalara.com).
3) If you do not receive the correct form within 48 hours, please contact our team immediately.
State by State Exemption Certificate Guide
Policies
I agree to the ION Reseller Terms and Conditions*
I agree to the ION Reseller Map Policy*
I agree not to sell ION on third-party websites*
Signature*

Clear
Should be Empty:

ION* Wholesale Practitioner Application

Application Information

Business Information

Additional Information

Tax Exemption

Policies