PRN Pharmacal Authorized Online Seller Application

Applicant Information

Date of Submission

Applicant's Legal Name

DBA/Trade Name(s)

Requested Website

Please identify all websites or mobile applications through which you wish to sell Pet-Ag, Inc. products (one per line, exact spelling required). Example: www.ABCStoreName.com Example: Amazon.com / Storefront name “ABC Store”/ Merchant ID

Primary Contact

Primary Contact Title

Secondary Contact

Secondary Contact Title

Business Physical Address

Mailing Address (If different)

Telephone

Fax

Entity Type

State of Incorporation

Year Incorporated

DUNS

EIN

Resale Certificate Number

Resale Certificate Issuing State

How long have you been engaged in e-commerce sales?

From which Authorized Distributor(s) have you purchased the PRN Pharmacal products?

Check all that apply:

From which Authorized Distributor(s) have you communicated with regarding the purchase of PRN Pharmacal products? Check all that apply.

Check all that apply:

Do you store or intend to store your inventory of PRN Pharmacal products at a location the Applicant Physical Address identified above.

Do you use any third-party fulfillment service or third-party logistics provider to store inventory or fulfill orders of PRN Pharmacal products (including any drop-shipping arrangement)?

Do you have the ability to provide monthly reporting of sales by item and zip code of shipped PRN Pharmacal to PRN or a PRN-designated data management organization?

Has the Applicant ever been a debtor in any bankruptcy, receivership, or other insolvency proceeding?

Has any company in which any of the Applicant’s principals hold an ownership interest ever been a debtor in any bankruptcy, receivership, or other insolvency proceeding?

Are there any pending lawsuits involving the Applicant?

Applicant Agreement

By submitting this Application and checking this box, Applicant acknowledges that authorization to sell on the Requested Websites is only granted once both Applicant and PRN Pharmacal. have executed the PRN Pharmacal. Authorized Online Seller Agreement, accessible below. https://www.prnpharmacal.com/brand-support/

Applicant Agreement

By checking this box, Applicant agrees that if Applicant is approved to sell PRN Pharmacal products on any or all of the Requested Websites, it will abide by the terms in the PRN Pharmacal Authorized Online Seller Agreement with respect to any approved websites.

Applicant Agreement

By checking this box, Applicant acknowledges that it has read all terms in the PRN Pharmacal Authorized Online Seller Agreement.

Applicant Agreement

Applicant indicates its agreement to the terms of the PRN Pharmacal Authorized Online Seller Agreement by checking this box.

Applicant's Signature

Applicant indicates its agreement to the terms of the PRN Pharmacal Authorized Online Seller Agreement by typing Applicant’s name here:

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