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Practitioner Name (First and Last)

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Practitioner Phone

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Practitioner Email

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State Licensed In

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NPI Number (N/A if unknown)

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NPI Type (N/A if unknown)

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Consent/Confirmation for communication from my lab box including tracking

Yes, I have read and understood the Proposition 65 requirements for warning stickers to be applied to specific PRL products (the list of which I have also reviewed) that I sell in the state of California

By checking this box and typing my name below, I am electronically signing my acknowledgement that I have read and understood the provided information regarding Proposition 65.

First Name

Last Name

Date

DBA Name (Doing Business As)

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.

You are required to choose one of the following two options.

Opt-In to Client Direct Program

By check this box, I acknowledge that, as an authorized healthcare practitioner enrolled in the Premier Research Labs (“PRL”) Client Direct Program, I am eligible to receive a commission of up to forty percent (40%) on the net sales of PRL products (excluding taxes, shipping, discounts, and fees) purchased directly by clients using my assigned practitioner referral code. I understand that commission eligibility is limited to qualifying orders placed directly with PRL and properly attributed to my referral code through the Client Direct Program. I further acknowledge that PRL may modify the commission rate, payment terms, eligible products, or other aspects of the Client Direct Program at its sole discretion at any time, with or without prior notice.

Opt-Out of Client Direct Program

By checking this box, I acknowledge that I have been informed of the Premier Research Labs (“PRL”) Client Direct Program and understand its terms, including the availability of commissions for client purchases made directly through PRL using a practitioner referral code. I elect not to participate in the Client Direct Program at this time and voluntarily waive any right to receive commissions on purchases made by my clients through PRL’s Client Direct ordering platform. I understand that I may request to enroll in the Client Direct Program in the future, subject to PRL’s approval and the then-current terms and conditions of the program.

I understand that based on the site and how you have it coded that you may need to make modifications in terms of how it appears on the registration as well as how it appears for existing practitioners. Please let me know if you have any questions or I may help in any way.

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20” x 59”

Cotton Flannel, Premier
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Oral Poultices with Bentonite Clay and Zeolite

Medi-Detox Pack Premier External Cleansing Clay Pack
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Premier foot soak or whole body soak

Medi-Soak® Cleanse Premier Bath Salts Formula with ocean-rich sea vegetation
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Organic castor oil, for use with castor oil packs, as well as skin softening and nourishment

Organic Castor Oil, Premier Softens and Nourishes Skin
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pH Minerals, Premier (2 oz) Promotes Whole Body Mineral Health*
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A richsource of ionic magnesium and many other trace minerals, including sulphur, boron, lithium, and more

pH Minerals, Premier (8 oz) Promotes Whole Body Mineral Health*
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15 foot roll

pH Paper Roll 15 Foot Roll
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Unrefined sea salt with critical trace elements, featuring two premium, untreated, unheated, solar-dried sea salts from Australia and Hawaii

Pink Salt, Premier (12 oz) Premium Blend of Unrefined Sea Salts with Hawaiian Volcanic Clay

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