Wholesale Application Form- Business Entity Accounts
Account Registration: Business Entity
Business Entity
*
Business Entity Name
Practice Name/ DBA Business Entity (if different)
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / 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 this Business Entity that will be using this account:
*
Practitioner First Name
Practitioner Last Name
Practitioner Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Practitioner License Number
*
Practitioner Specialty
*
Please Select
MD
DO
PA-C
NP/ APRN
Licensed ND
LAc
DC
PharmD
Licensed DOM
DDS
Other
Copy of Practitioners License / Certification
*
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If "other" specialty is selected, please specify license type:
Practitioner # 2:
Practitioner First Name
Practitioner Last Name
# 2. Practitioner Phone Number
Please enter a valid phone number.
# 2. Email
example@example.com
# 2. Practitioner License Number
# 2. Practitioner Specialty
Please Select
MD
DO
PA-C
NP/ APRN
Licensed ND
LAc
DC
PharmD
Licensed DOM
DDS
Other
# 2. Copy of Practitioners License / Certification
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# 2. If "other" specialty is selected, please specify license type:
Practitioner # 3:
Practitioner First Name
Practitioner Last Name
# 3. Practitioner Phone Number
Please enter a valid phone number.
# 3. Email
example@example.com
# 3. Practitioner License Number
# 3. Practitioner Specialty
Please Select
MD
DO
PA-C
NP/ APRN
Licensed ND
LAc
DC
PharmD
Licensed DOM
DDS
Other
# 3. Copy of Practitioners License / Certification
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# 3. If "other" specialty is selected, please specify license type:
Practitioner # 4:
Practitioner First Name
Practitioner Last Name
# 4. Practitioner Phone Number
Please enter a valid phone number.
# 4. Email
example@example.com
# 4. Practitioner License Number
# 4. Practitioner Specialty
Please Select
MD
DO
PA-C
NP/ APRN
Licensed ND
LAc
DC
PharmD
Licensed DOM
DDS
Other
# 4. Copy of Practitioners License / Certification
Browse Files
Drag and drop files here
Choose a file
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# 4. If "other" specialty is selected, please specify license type:
Acknowledgements
We understand that in order to carry the R3AL3 LIFEGEVITY brand, qualified healthcare professionals are required to hold current, active, and non-restricted licenses to practice, and that R3AL3 LIFEGEVITY has a right to request proof of licensure for any qualified healthcare practitioner at any time while we carry the products.
*
Acknowledged
We agree to abide by R3AL3 LIFEGEVITY's policy on internet sales, in that in no event shall we, or any individual practitioner at our company, sell any R3AL3 LIFEGEVITY products through any third-party seller, such as Amazon or eBay.
*
Acknowledged
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