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Become a Registered XYMOGEN Practitioner

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XYMOGEN formulas can be obtained only through a licensed healthcare practitioner. If you would like additional information on how to partner with XYMOGEN, please fill out the form below to begin the application process.

*Denotes Required Field

Contact Info


*First name
*Last Name
*Title
*License #
*Phone
*Email
*Zip or Postal Code
*Country
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Application

NEW ACCOUNT APPLICATION


PRACTICE/BUSINESS LOCATION

NOTE: Please send a copy of your Current Business License and/or Resale Certificate to new.accounts@xymogen.com


BILLING ADDRESS (if different from above)

Contact Information

Would you like to subscribe to XYMOGEN email communications?

Will you be promoting XYMOGEN products through this website?

PREFERRED PAYMENT METHOD
For credit card payments, please contact XYMOGEN Customer Service by phone to process the transaction.
ADDITIONAL INFORMATION

Whom do we thank for referring you?

Please name the three most common conditions you treat:

Which brands do you currently carry in your practice?

Any additional comments/requests?

Please note

All of the documents below are required before we can open your account. Please ensure that all required documents are signed, dated, and filled out in their entirety to avoid any unnecessary delays in our review process. If any of these documents are missing or incomplete, your wholesale account cannot be established. Please contact the New Accounts department if you have any questions.

  • New Account Application
  • Customer Protection Agreement
  • No Internet Sales Policy
  • Return Policy
  • Copy of current business license and/or resale certificate

Customer Protection Agreement

This Agreement is between the signed health care professional (“CUSTOMER”) and XYMOGEN. CUSTOMER shall not disclose XYMOGEN pricing on the Internet or supply XYMOGEN products to any re-sellers or retailers.
THIS XYMOGEN CUSTOMER PROTECTION AGREEMENT (“Agreement”) is made as of this day of , 20 (the “Effective Date”), by and between XYMOGEN, Inc. (“XYMOGEN”), an Illinois corporation, with its principal place of business located at 6900 Kingspointe Parkway, Orlando, FL 32819; and the health care professional, (“CUSTOMER”), with its principal place of business located at
In consideration of the mutual promises and covenants herein, XYMOGEN and CUSTOMER (“Parties”) do hereby agree as follows:
XYMOGEN and CUSTOMER (“Parties”) agree as follows:

XYMOGEN
Signature:
signature”
Print Name:
Brian J. Blackburn, President/CEO

Exhibit "A"



*Customer Name:(Print)
*Signature:

Exhibit "B"

*Customer:(Print)
*Signature

Return Policy



*Printed Name:
*Signature:
*Date:

Thank You

Thank you for filling out your Application!

We will review your application and contact you if we have any questions or need any additional information. Should your application be approved, XYMOGEN will be able to setup your account for online ordering using the email address you provide.

If you have any questions or concerns, please do not hesitate to contact us. We are happy to help and look forward to working with you!

Your Tracking Number for this application is: . This number will also be emailed to you.

If you are participating at a XYMOGEN Event and have been given an Authorization Code to request an order, please enter the code below. This order will only be placed pending approval of your account.
Authorization Code:

If you prefer to download the form and submit by email (new.accounts@xymogen.com), fax (321-251-4674) or mail (6900 Kingspointe Parkway Orlando, Florida 32819), choose your location below.

United States Canada

If you need a W9 form, you can download that from the IRS by clicking here.

Upon submission of your application, you may be contacted for follow up inquires. If you have questions or concerns throughout the process, please do not hesitate to contact us. We are happy to help and look forward to working with you!

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*These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.