Affiliate PRE-QUALIFICATION Form

    Referred by:        Name of Referring Entity

    First Name     Last Name       Title    

    Company      Address

    City                State      Country     Zip 

    Company Address  

    E-mail  Address     Cell Phone    

    Wk Phone                  Hm Phone          

        Direct Sales Experience     Internet Marketing Experience  

        Advertising Experience     Computer Skills

        Knowledge of the Pharmaceutical Industry

        Current Occupation Years

        Your URL (web site)  

          For Individuals: Check only the boxes that reflect your status.          

I'm a licensed physician.    I'm a pharmacist.    I operate in the Health Industry.

          I represent a large organization, union, non-profit or other large potential buyer.

I'm currently affiliated with another online pharmacy.

If approved, I wish to start Full-Time. 

          If approved, I'm ready to start  immediately.

          I have instant access to numerous potential buyers.

          I have been convicted of a crime in the last 5 years.

          For Companies and Organizations only. Check all the proper boxes.

We want to offer the savings of the pharmacy to our customer/membership base as an added benefit.

We want to promote the availability of the pharmacy among other organizations.

          We want to purchase pharmaceuticals in large quantities (only when permitted by law).

          We want to advertise the availability of the pharmacy in large scale.

          Nature of the Company or Organization   

          Position with the Company                     

        

         I hereby certify that the above statement are true and to the best of my knowledge.