NDC3418 | National Drug Card / FluffyRx Agent Agreement Terms

Agent Affiliate Program Agreement

Provided by NDC
Name*

First NameLast Name
Year Born*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Website
Affiliate Type*

IndividualPharmacy Industy / PharmacistDigital Marketer / BloggerNon-Profit OrganizationSole ProprietorPartnershipAssociationCorporation
NDC Agent Agreement
Please review, print and/or download the
NDC Agent Agreement PDF linked below.
Electronic Signature*
Signing above has same bond as written signature.
Company Name (Optional)
Date*
Month/ Day / Year
By clicking the submit button, I agree to terms & conditions provided in the Agent Agreement PDF document linked above.
Should be Empty: