PROFESSIONAL ACCOUNT REQUEST

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Please complete the information below and allow 1 business day for your account to become active. Your information will not be sold to others, nor will it be used by anyone other than Hummingbird Therapeutics. The information you share with us helps us to assure that qualified professionals are receiving discounts, and to enhance and simplify your shopping experiences at Mother Anita's. In a hurry? Check out our quantity discounts online available to all buyers.
For more privacy information please go to privacy tab at the bottom of the home page.

* items marked with an asterisk must be completed prior to approval

Personal Information

*Email Address: _____________________________________

*Desired Password: ___________________________________


SS#/EIN#/Reseller Number:_____________________________
(required by law if you resell to retail customers. This information is used by Hummingbird Therapeutics only and will allow you to be tax exempt)This can be called in if you are emailing your application.

______________________________________________________________________

Title: _____________________
* First Name: ___________________________________
* Last Name: ____________________________________

* Business Name/DBA: ____________________________________________________________

*Job Title : ______________________________________________________

* Mailing Address: ________________________________________________

*City: ___________________________________________________________

* State: __________________________________________________________

*Zip Code: ________________________________________________________

/Country: _________________________________________________________

* Daytime Phone: __________________________________________________

Cell Phone: ________________________________________________________

Home Phone: _______________________________________________________
* Best Time to Call:    AM     PM

________________________________________________________________________

Professional Credentials

To be considered for professional pricing, please complete the following fields. If you do not complete all fields you will not be considered for professional pricing. We may contact you if needed prior to setting up your account.
All Medical, Massage, Alternative Healing, and Personal Care modalities will be considered for professional pricing

*Professional Work Performed: ____________________________________________________________

*Where are you licensed? City: _____________________________________________
                                             State: ____________________________________________

* License Number: _________________________________________________________

If you have not provided licensing information, please explain:
___________________________________________________________________________

____________________________________________________________________________

_____________________________________________________________________________


*What training institutions have you attended/are you attending? (Please, no abbreviations)

______________________________________________________________________________

______________________________________________________________________________

Are you currently a student?   Yes          No


*Years Experience: ________________________


Choose?
                Please do not solicit me by post office mail.
                Please do not solicit me by email.
(Please note that we may need to call or email you regarding your website account, product orders, or catalog requests)


Your Website: ______________________________________________________________


Please Fax completed for to 603.424.9135
or mail to the address below.

Hummingbird Therapeutics
PO Box 730      16 Edward Lane
Merrimack, NH 03054
603-424-2030