Home Acyclonine MUM Credentialing Section Prescriber Information (Required only once for first time orders) Step 1 of 4 25% Provider ProfileProvider's Name(Required) Facility Name(Required) Reference Code Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)FaxEmail(Required) State and License Number(Required) Expiration Date(Required) MM slash DD slash YYYY Type of Practice:(Required) Please provide the facility name(s) and address(es) for all locations you practice at and will be purchasing and dispensing pharmaceutical items:Attach State Licensing Drop files here or Select files Accepted file types: jpg, png, pdf, jpeg, Max. file size: 5 MB, Max. files: 5. Physician’s Facility Information(Please complete all questions, as questionnaires with blank answers will not be processed.)Has your medical license ever been revoked, suspended, reprimanded, restricted, or placed on probation by a medical licensing board or other entity?(Required) Yes No Are you currently under investigation or the subject of pending disciplinary action by any #edical licensing board, health care facility or other entity?(Required) Yes No Is your medical license currently restricted in any way or have you ever been fined by any medical licensing board or other entity:(Required) Yes No Have you ever been convicted of a crime relating to the distribution of prescription drugs or a violation of any federal or state law?(Required) Yes No Have you ever discontinued the practice of medicine for any reason for one month or more?(Required) Yes No Have you ever been arrested, indicted, or convicted, plead guilty, or pled nolo contendere for violation of any federal, state, or local law (other than a minor traffic violation)?(Required) Yes No If you answered “yes” to any of the questions above, please give a brief description:By signing below, Provider represents and certifies that all information in this Application is complete, accurate and truthfulProvider's Name(Required) Signature(Required)Title(Required) Date(Required) MM slash DD slash YYYY Physicians Designation of Authorized Purchasing Agent(s)Select(Required) I do not authorize anyone to act on my behalf at this time. I will place my own orders. I authorize my agent(s) to place orders on my behalf. Designated Agent(s)Name - Agent 1 Title - Agent 1 Signature - Agent 1Date MM slash DD slash YYYY Email - Agent 1 Agent 2 (if needed)Name - Agent 2 Title - Agent 2 Signature - Agent 2Date MM slash DD slash YYYY Email - Agent 2 I certify that all the information I have provided is true, complete and correct.Provider's Name(Required) Signature(Required)Title(Required) Date(Required) MM slash DD slash YYYY Medical Provider Terms and Conditions of SalesI agree to the following statement(Required) Provider acknowledges that all Nubratori RX products are for office use only and not be to re-sold. Provider can only dispense or administer Nubratori RX products to its own patients.Following are the Terms and Conditions of all sales and transactions between Nubratori RX and medical providers, all hereinafter collectively referred to as “Provider.” By signing below, Provider acknowledges and agrees that all transactions between Provider and Nubratori RX are subject thereto: Provider acknowledges that all orders placed for Nubratori RX products are for patients that the provider believes will have a significant clinical difference over other commercial products on the market. Provider agrees NOT to alter or tamper with the labeling or packaging of any Nubratori RX product. Provider understands and agrees that pricing for Nubratori RX products are subject to change without prior notice. Provider understands and agrees that some Nubratori RX products are only sold in case sizes/quantities. Provider agrees to report any order discrepancies within two (2) business days. Provider agrees that any unused, expired, or unwanted Nubratori RX products are to be disposed of according to all local, state and federal laws or regulations applicable to their licensure and the jurisdiction in which they conduct business. Provider acknowledges that Nubratori RX products cannot be returned. Provider must strictly abide by and observe all shipping, storage, return and non-circumvention policies of Nubratori RX, and Provider further agrees to store and handle all products in proper and appropriate conditions and temperatures as per manufacturer labeling, industry custom, and applicable laws and regulations concerning such. Provider agrees to observe and abide by all local, state and federal laws, rules and regulations applicable to their licensure and jurisdictions in which they conduct business. Provider agrees to indemnify and hold Nubratori RX harmless for all losses or damages suffered as a result of violations of these Terms and Conditions, or as a result of violation of any local, state or federal law or regulations concerning the possession, administering or dispensing of Nubratori RX products. Provider represents and confirms that it is fully insured for any liability or loss that may arise in connection with the purchase, possession, administering or dispensing of Nubratori RX products. Provider agrees NOT to display any Nubratori RX product on their website or other electronic medium without Nubratori RX’s prior written consent. Provider agrees NOT to use or disseminate any marketing material concerning or advertisement relating to Nubratori RX products without the prior, written consent of Nubratori RX prior to such use. Provider understands and acknowledges that in certain circumstances certain Nubratori RX products may not be available due to manufacturing back-order issues beyond the control or scope of Nubratori RX. Provider shall NOT attempt to, or actually, copy, imitate, or create any products similar, same as, or competitive against those offered by Nubratori RX. Provider is fully aware and acknowledges that all Nubratori RX products are protected by patents and/or pending patents, and all labeling and marketing material is protected by copyright and/or trademark, and, further, Provider specifically agrees NOT to violate such patents, trademarks or copyrights, nor to engage in any activity inconsistent therewith by attempting to, or actually, copying or imitating any Nubratori RX product, labeling, or marketing material. All orders must be pre-paid by Provider prior to shipping from Nubratori RX’s facility. For orders under $5,000, a credit card is acceptable means of payment. For orders over $5,000, 50% non-refundable deposit shall be wired at time of order and the balance must be wired by Provider to Nubratori RX prior to shipping. Accounts qualify to submit an application for credit after being established with Nubratori RX for at least six months. Credit will be granted or denied pursuant to the unfettered discretion of Nubratori RX, and subject to these Terms and Conditions, and any breach or violation of these Terms and Conditions by Provider shall also constitute a breach and violation of credit extended to Provider. Nubratori RX requires one or more personal guarantees for the extension of credit to Provider and to guarantee Provider’s strict adherence to these Terms and Conditions. Nubratori RX reserves the right to accept or reject any order. Furthermore, Nubratori RX reserves the right to cancel any order or account at any time, without recourse, and pursuant to its unfettered discretion. Nubratori RX retains the right to change, modify or alter its Terms and Conditions of Sales at any time. Any and all dispute arising from, or relating to, any sale or transaction between Provider and Nubratori RX, or arising from or relating to these Terms and Conditions of Sales, shall be governed by California law and be brought exclusively in the Superior Court of California, County of Los Angeles. The prevailing party in such dispute, action or proceeding shall be entitled to their attorneys’ fees and costs, in addition to any other relief allowed by law or so granted by the court. Signature(Required)Date(Required) MM slash DD slash YYYY By(Required) (Print name)Its(Required) (Corporate/organizational capacity or title of signer)It is so agreed: _________________________ __________ Nubratori RX / Date By: Joe DeKellis Its: General Counsel
