Partner Application - PN Medical Partners Portal

Company / Applicants Legal Name*
Application Type - Reseller / Affiliate*
Select reseller if you are intending to purchase a PN Medical product for resale. Select affiliate if you are intending to promote the product, with purchasers buying directly from PN Medical. Select both if you are interested in both a reseller and an affiliate relationship
Select the Product(s) you wish to carry or represent
DBA / Trade Name(s)*
List all applicable company names (d/b/a's) that will be used to sell The Breather and if applicable Breather FIT. (ONE name per line - exact spelling required) Thank you!
Primary Contact*
First Last
Title*
Phone*
FAX
Email*
Enter Email Confirm Email
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Shipping Address (if different from Physical)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Website - Primary*
Include http:// before URL
DUNS
EIN
Resale Certificate Number
Resale Certificate Issuing State

Where do you store your inventory?*
Do you store it on-site, at a fulfillment location, etc.
Has your company ever declared bankruptcy?*
- Yes
- No
Do you have any pending lawsuits?*
- Yes
- No
Similar or Complimentary Products*
List other products you work with that are similar or complimentary to Company products.
Apply for Online Sales*
Please identify ALL websites or mobile applications through which you wish to market for sale and sell PN Medical products (ONE per line - exact spelling required) Example: www.ABC StoreName.com Example: Amazon.com, Storefront name, "ABC Store" / Merchant ID
Reseller Agreement (please read)
Click HERE to view the Partner Agreement (opens in its own window). Please email or call the Partner Manager if you have any questions. By submitting this form, I agree to the terms of the reseller agreement.
Captcha - Check box if you are a person
Name
This field is for validation purposes and should be left unchanged.