Healthcare Resell Inquiry Company Name* Buyers Full Name* First Last Business Phone*Direct PhoneEmail* Health Care Professionals Full Name* First Last What type of Health Care Professional?*Select OneAcupunctureChiropractorMassage TherapistPhysical TherapistOtherIf other, please list type of healthcare professional: Health Care Professional License Number* Attach copy of your business Resell Tax IDMax. file size: 50 MB.Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Shipping Address* Same as Billing Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you currently sell Sombra Pain Relief products to your patients/clients?* Yes No How long have you been selling Sombra Pain Relief Products?Select One1-5 years6-10 years11-20 years21-30 yearsWho do you currently purchase the Sombra Pain Relief Products from? Are you open to walk-in clients to purchase the Sombra Pain Relief Products? Yes No Can we include your business on our referral listing? Yes No What topical Pain Relievers do you currently sell? How did you hear about ordering Sombra Factory Direct?*Select OneEmailChiropractic Economics AdMassage Magazine AdFlyer with marketing materialsWebNew Mexico Chiropractic Association (NMCA)OtherIf other, please specify:*
