Business Entity*

Business Entity Name *

Practice Name/DBA of Business Entity *

Business Address*

Street Address *

Street Address Line 2

City *

State *

Postal/Zip *

Country *

Copy of Resale Tax License

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-64691-file2-1_

Please list ALL qualified healthcare practitioners listed under the Business Entity that will be using this account

Practitioner First Name

Practitioner Last Name

Practitioner Phone Number*

Email *

Practitioner License #

Practitioner Specialty

OTHER

Copy of Practitioners License

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-64691-file2-2_

Practitioner 1

Practitioner First Name

Practitioner Last Name

Practitioner Phone Number*

Practitioner License #

Practitioner Specialty

OTHER

Copy of Practitioners License

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-64691-file2-3_

Practitioner 2

Practitioner First Name

Practitioner Last Name

Practitioner Phone Number*

Practitioner License #

Practitioner Specialty

OTHER

Copy of Practitioners License

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-64691-file2-4_

Practitioner 3

Practitioner First Name

Practitioner Last Name

Practitioner Phone Number*

Practitioner License #

Practitioner Specialty

OTHER

Copy of Practitioners License

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-64691-file2-5_

Practitioner 4

Practitioner First Name

Practitioner Last Name

Practitioner Phone Number*

Practitioner License #

Practitioner Specialty

OTHER

Copy of Practitioners License

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-64691-file2-6_

Thanks for your Alight Health application form!

We appreciate you applying for an Alight Health Formulas account with us! Our customer care team will be in touch with you shortly on the status of the approval of your account! Please wait up to business 24-hrs. Thank you!

Have a great day!

Your Friends at Alight Health Formulas

Thanks for your Alight Health application form!

Have a great day!

Your Friends at Alight Health Formulas

Wholesale Application Form - Business Entity Accounts

Business Entity*

Business Address*

Please list ALL qualified healthcare practitioners listed under the Business Entity that will be using this account

Practitioner 1

Practitioner 2

Practitioner 3

Practitioner 4

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