Professional account application

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Professional account application

Clinic/Business Name

Name

Email Address

Phone Number

Shipping Address

As part of this application, we request you submit the following documents:

Professional Training Documentation

State recognized licensed practitioners

Please provide the license number and the state in which you practice. Uploading diploma or record of training is optional.

State

Kind of Practice

License Number

Documentation of training

Accepted file types: pdf, docx, doc, odt. File size limit: 3mb

Other Practitioners/Professionals

Please provide diploma, record of training, and/or a certificate of completion.

Documentation of training

Accepted file types: pdf, docx, doc, odt. File size limit: 3mb

Students (Practitioners/Professionals in Training)

We love students. Please provide student ID from an established school. We recognize many schools do not have official IDs distributed. Email acceptance into a school or other forms of communication with the school will be accepted.

State

Name of School

Documentation of training

Accepted file types: pdf, docx, doc, odt. File size limit: 3mb

Optional: Tax Documentation

California Residents: to be eligible for tax-free sales, please complete and submit CDTFA-230 Form.

Resale certificate

Accepted file types: pdf, docx, doc, odt. File size limit: 3mb

How did you hear about us?

How did you hear from us - Conference:

How did you hear from us - Sales Representative:

How did you hear from us - Additional details

Please add me to your mailing list for:News & SalesNone

* emails & personal information are never and will never be released or sold to third parties

Thank you for your application.

You will be notified after your account has been reviewed. If you have not created a basic account, you can do so now by clicking here.