Practitioner Application Form

If you wish to apply for a practitioner account, please fill in the information below. We will review this information before getting back to you as soon as possible.

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Company Name:
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Contact Name:
Registered No:
VAT No (if applicable):
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Contact Telephone Number:
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Description of Business:
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Email:
Website Address:
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Account Password:
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Confirm Password:
Business Name/Address to:
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Address Line 1:
Address Line 2:
Address Line 3:
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Town/City:
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Country:
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Postal Code:
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Certificate of Membership:
Please upload a copy of your certificate of membership with the appropriate regulatory body. (e.g. Association of Naturopathic Practitioners, National Institute of Medicinal Herbalists)
Enroll for the practitioner referral scheme:
 
This scheme enables you to get 15-25% commission on orders referred to us. Terms and conditions apply.
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How did you hear about us?
Allow communication:
 
Tick the box above to receive practitioner communications from us regarding promotion and latest products
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Please add the two numbers