Vendor Registration

Registration

Username*

Email*

First Name

Last Name

Store Name*

https://dealsmedi.com/store/[your_store]

Address 1*

Address 2

Country*

City/Town

State/County

Postcode/Zip*

Store Phone*

EIN Number*

Business Registration (LLC / Corporation / Sole Proprietor)*

Business Registration Certificate*

Sales Tax / Resale Certificate*

Government ID Upload*

Business State*

Store Description*

Product Category (Medical Category)*

Business Website

I have read, understood, and agree to the Vendor Agreement.*

Business Registration Expiry*

Sales Tax Certificate Expiry Date*

Government ID Expiry Date*

Vendor Document Status

W-9 Tax Form*

General Liability Insurance*

Product Liability Insurance*

Signed Vendor Master Agreement*

Signed FDA Compliance Declaration*

Signed HIPAA Compliance Declaration*

FDA Establishment Registration Number

FDA Device Listing Number

DME License

Password*

Confirm Password*