US Reseller Application

FORM-QR-0244-00

My Company is a:*

Pharmacy

DME Supplier

National Distributor

Other

Company name*

First name*

Last name*

Email*

Billing Address Line 1*

Billing Address Line 2

Billing City*

Billing State*

Billing Zip Code

Billing Country*

Phone number*

Website URL

If Ship To information is different than above, please complete the following billing fields.

Shipping Address Line 1

Shipping Address Line 2

Shipping City

Shipping State

Shipping Zip Code

Shipping Country

Shipping Phone

Why do you want to sell NasoNeb* products?*

What challenges is your pharmacy currently facing?*

How many prescribers do you work with in your area?*

What NasoNeb* competitors do you sell?

Payment Terms

Desired Terms: PrePaid or Net 30
* If requesting Net 30 credit terms a Customer Service Representative will send you a credit application separately
Until Net 30 status is approved, account remains in prepaid status.*

Please also provide:

A copy of your business tax certificate and state seller's permit
A completed state Sales Tax Exemption Certificate

Upload your files here*