New Customer Account Application

Section I: Shipping Account Information Business Name* Physician Name* - include acronym Address* City* State* Zip Code* Telephone Number* Fax Number Referred by

Section II: Mailing Information Mailing/Billing Address City State Zip Code Telephone Number Fax Number Cellphone Number or Additional Phone Number Website Address (if applicable) Email Address*

Section III: Nature of Business

Is this a consulting office?*

Yes No

Do you perform AK, EDS or NRT testing?*

Yes No

Are you part of a group practice or a single practitioner?*

Single Group State License Number* State* Expiration Date (mm/dd/yy)* DEA Number (if applicable) State Expiration Date (mm/dd/yy)

By checking this box, I certify that the information provided above is true and correct to the best of my knowledge, information and belief, made after diligent inquiry and that I am authorized to sign on behalf of applicant.

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New Customer Account Application