Business Name

Business Address

City

State

Zip

Business Type Business Type *Choose oneLLCCorporationSole Proprietor

Website Domain

Business EIN

Primary Contact Full Name

Email Address

Phone

Role / Title

Do you need a new domain name? Do you need a new domain name? Yes No Unsure

Preferred Store Name

Are you able to maintain the $500 fulfillment retainer? Are you able to maintain the $500 fulfillment retainer? Yes No

Which Solution are you interested in? Which Solution are you interested in? *Managed ServiceSelf Managed Plugin Which Solution are you interested in?

Are you prepared for the $495 one-time setup fee? Are you prepared for the $495 one-time setup fee? Yes No

Are you prepared for the $295 monthly platform subscription? Are you prepared for the $295 monthly platform subscription? Yes No

Are you prepared for the $1195 one-time license fee? Are you prepared for the $1195 one-time license fee? Yes No

Are you prepared for the $395 annual license renewal? Are you prepared for the $395 annual license renewal? Yes No

Do you understand that you must provide labels for all orders? Do you understand that you must provide labels for all orders? Yes No

Have you reviewed our Compliance Requirements page? Have you reviewed our Compliance Requirements page? Yes No

Will you comply with all research-only requirements and product restrictions? Will you comply with all research-only requirements and product restrictions? Yes No

Do you understand that medical, therapeutic, or human-use claims are prohibited? Do you understand that medical, therapeutic, or human-use claims are prohibited? Yes No

Additional Notes