Affiliate Signup Form

Affiliate Signup Form
Contact Details
Name

First NameLast Name
NPI Number
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you interested in becoming an affiliate or a wholesaler?*

Affiliate (Receive 30% commission)Wholesaler (Sell for, at minimum, 2x the wholesale price)
Commission Payment
Commission payments are made monthly to your PayPal account. You don't need to have a business account, a standard PayPal account is acceptable.
PayPal Account Email
example@example.com
Please allow 2-3 business days to process. You will be notified by email when it is ready.
Should be Empty:

Contact Details