Health Care Professional Account Registration

Please be aware while your account is pending qualification you will have access to our full supplement product line at retail pricing, excluding vastu products. Once approved, your pricing level will be adjusted to wholesale cost and access will be granted to vastu products.

You have 14-days to provide your Account Management Team with the required documentation for review. After the 14-days your account will become inactive.

Contact Information

Full Company Legal Name (This will be your account name)

DBA Name (Doing Business As)

First Name

Last Name

Email (This will be your account ID when you log in)

Business Phone Number

Mobile Phone Number

Providing us with your mobile phone number will allow us to quickly identify you should you have any issues accessing your account

Opt-in to receive text message and/or email notifications specific to your account, exclusive offers and more.

By providing my mobile phone number and email address, I agree to be contacted by Premier Research Labs. Standard text messaging and data rates may apply.

Enter Password

Password Strength: No Password

Re-Enter Password

Address

Street Address (Billing)

Address

City

State/Province

Zip/Postal Code

Country

Certification Type

Upon request, Health Professionals may need to provide a copy of their applicable professional license or certificate.

Please enter Certification Type for "Other"

Retailer License/Certification Number

Where did you get certified? (Certifying Body)

Resale Restrictions

Please identify the URL for each website where you sell or intend to sell PRL Products (including any ePharmacy website described more fully below). If you do not sell or intend to sell the PRL Products on any online forum, mark “N/A” below.

Please note that consent to sell the Products on online marketplaces (including but not limited to Amazon, eBay, and Walmart Marketplace) is not granted through this Registration and Authorization Form.

Permissible Public Website Sales: If you presently sell or are interested in selling the PRL Products on your own proprietary website, the website must (i) be operated by you in your own legal or registered fictitious name, (ii) conspicuously state your legal name or registered fictitious name and contact information, (iii) not give the appearance that they are operated by PRL or any third party, (iv) have been registered with PRL through this Registration and Authorization Form, and (v) be operated in compliance with the Premier Research Labs Online Sales Guidelines, which are set forth in the Authorized Professional Resale Agreement of Premier Research Labs, LP.

ePharmacy Sales: If you presently sell or are interested in selling the PRL Products through an “ePharmacy,” please also disclose it in the Authorization and registration Form. An “ePharmacy” is a website, micro-site, or other mobile application that (i) is operated by a distributor in a distributor’s legal name or registered fictitious name, (ii) is primarily used to facilitate Product orders from end users on your behalf, (iii) requires the prospective end user to create an account with your preapproval and log-in to purchase the Products, and (iv) is operated in compliance with the terms and conditions set forth in the Premier Research Labs ePharmacy Online Guidelines, which are set forth in the Authorized Professional Resale Agreement of Premier Research Labs, LP.

From which sources, including PRL and all distributor(s), do you or do you intend to purchase PRL Products?

By checking this box, I agree, on behalf of the health care practitioner reseller, as follows:

I have read, accept, and agree to abide by the Terms of Use and the Authorized Professional Resale Agreement of Premier Research Labs, LP (“Agreement”), and I represent and certify on behalf of the health professional reseller that (a) all of the information submitted in this Registration and Authorization Form is true, correct, and current and (b) my checking of this box is intended by me to record such agreement as if actually signed by me, including my agreement to adhere to the Agreement.

FOR INFORMATIONAL PURPOSES ONLY: PRL has a unilateral minimum advertised price policy in the United States for certain of its Products, accessible here (MAP Policy). The purpose of this section is to alert you to the existence of the MAP Policy. PRL does not solicit and it does not accept any assurances of compliance with the MAP Policy from any of its health professional resellers. The MAP Policy also does not constitute an agreement between PRL or any other person or entity. Each health professional reseller must independently decide whether to comply with the MAP Policy.

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