Promedics

* = optional field

Education
School attended:
Year Graduated:
Professional Degree/Registration/Certification:
	ND DC MD Other
License/Registration/Certificate# :
PLEASE FAX/MAIL A COPY OF YOUR CERTIFICATE

Practice
Type of practice/specialties*:
Number of health-care professionals in practice*:
Do you sell other professional products?
Brands?*

Payment terms desired
Auto Visa/MC/Amex:	(2% discount on order when prepaid by credit card)
Credit card at time of purchase:	(credit card # not kept -2% discount on order)
Net 30 days:	(No discount on order)

ProMedics Nutraceutical Ltd. is committed to providing high-quality products, excellent service and education to support you and your patients. Thank you for taking the time to complete the application. Do not hesitate to call if you have any questions.