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Please complete the
information below and allow 1-2 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
Company
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: _______________________________________________________
* Your Business Shipping
Contact: ___________________________________________
* Your Accounts Receivable Contact: _______________________________________________
* Mailing Address: _______________________________________________________________
*City: ________________________________________________________________
* State: _______________________________________________________________
*Zip Code: ___________________________________________________
Country: _______________________________________________________
*
Daytime Phone: ________________________________________________
Cell Phone: ______________________________________________________
Home Phone
: ____________________________________________________
*
Best Time to Call AM PM
Fax: ____________________________________________________________
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To be considered for Wholesale pricing, please complete the following fields. If you do not complete all fields you will not be considered for Wholesale pricing. We may contact you if needed prior to setting up your account.
All re-sellers
of products online, brick and mortar stores, and healing
professionals will be considered for Wholesale pricing.
* Storefront is:
Virtual - Brick and Mortar (circle any that
apply)
Your Website/s: _______________________________________________
D&B Number : __________________
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)
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