Wholesale Sign-Up Form

Precision Nutrients - Practitioner Access Program

Practitioner & Business Information

Practitioner first name

Practitioner last Name

Professional Title

NPI# (if applicable)

License Number (if applicable)

Expiration Date

Phone Number

Business name

Website

Business email

Business Phone Number

Business Address

2nd line Address

City

State

Zip Code

Country

Is the business address and shipping address the same?

Yes

No - If no please fillout shipping address

Business Shipping Address

2nd line Address

City

State

Zip Code

Country

Business Details

Type of Practice

Estimated Monthly Order Volume

Preferred Payment Method

Tax Documentation & Resale Certificate (State Specific Compliance)

Legal Business Name

State Sales Tax ID Number

Issue Date

Certificate Type

Expiration Date

Please check the box that applies

Attach a Valid Resale Certificate

Not eligible for exemption, agree to sales tex

Attach Valid Resale Certificate Here

Terms & Acknowledgement

Please Check Each Box

I confirm all provided information is accurate and current

I acknowledge Precision Nutrients wholesale pricing is for licensed professionals only

I agree not to resell Precision Nutrients products on third-party marketplaces

I understand access may be revoked for non-compliance

Signature

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Make sure to review our Shipping & Return Disclaimer before proceeding.

Acknowledgment

By placing a wholesale order, I acknowledge that I have read, understood, and agree to the terms outlined in this agreement, including the shipping and return policies.

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Print Your Last Name