Authorized Partners Onboarding FormBecome a PEP19™ Distributor Company information Legal business name DBA (if applicable) Business structure (LLC, corp, etc.) Date established Website Primary business address City State Zip code EIN / Tax ID ReSale certificate / license Primary contact Full name Title / role Phone Email Secondary contact (optional) Full name Title / role Phone Email Business details Brief description of business Focus areas / target markets / product line interest Number of locations (if applicable) Estimated monthly sales volume ($) Sales and distribution channels Check all that apply: Check all that apply: Retail storefront Online e-commerce Medical / health clinics Other Licenses and compliance Relevant Certifications (Reseller license, pharmacy license, etc.) Insurance policy information Logistics Shipping address (if different than primary) City State Zip code Warehouse / receiving hours Financial information Accounts payable contact Billing email Tax-exempt status (if applicable): Tax-exempt status (if applicable): Yes No Preferred payment method Preferred payment method ACH / wire Credit card Other Marketing and branding Will you market and promote the products? Will you market and promote the products? Yes No If yes, please describe planned marketing channels Preferred container for capsulation (size/color) Preferred capsules (size/color) Labels Social media account links Distributor certifies that the information provided is accurate and agrees to comply with distributor program policies and all applicable regulations. Supporting documents to verify answers will be requested. Submit application
