Professionals

Account Type*
- Doctor or Clinic Account
- Health Care Professional
- Veterinary Account
- Distributor
- Affiliate *Note a W-9 Form is required
Business Information
Owner or Professional’s Name*
First Last
Specialty, Designation and Business Type*
Practioner ID and/or local Business License Number

MD, ND, LLc, Inc. sole proprietor, etc.
Issuing Organization, State and Date*
Issuing Organization State Date
Business Name*
Please attach a copy of the followings requirements:
- Business license/ Medical licenses and/or degree documentation
- Resale Permit ( California only)
Federal Tax ID*
California Resale # for CA State Tax Exemption Only-Verified at

https://onlineservices.cdtfa.ca.gov
W-9 Form: Affilates ONLY please fill out and upload

https://www.irs.gov/pub/irs-pdf/fw9.pdf
Upload your files here. If unable to upload please email to info@polymva.com
Drop files here or

Max. file size: 50 MB.
Please attach your own W-9 form or download the one HERE, fill out electronically or print, sign and upload.
Phone number*
Best time to contact you
Fax number
Email address*
Website
Referred By*

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Mailing Address
Name
First Last
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Charge Card Authorization Form
For purchasing upon approval
In order for us to accept and bill your charge card, please complete all fields.

Please provide the following information in connection with your order. All information kept on file is strictly confidential.
Card Holder Name
First Last
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
For international orders please complete this pdf and upload it below or email directly to info@polymva.com
Upload pdf Credit Card Release Form signed for purchase
Max. file size: 50 MB.
Credit Card
Credit Card number
Expiration Date
Security Code
Business Name if a Business Card
Authorization: I hereby authorize AMARC to charge the credit card indicated above. I agree not to dispute AMARC’s recurring billing with my charge card issuer, as long as the amount in question was for products rendered prior to the effective termination date. I agree that I will not dispute any charges from AMARC unless I have already attempted to rectify the situation directly with AMARC in good faith and those attempts have failed. I certify that I am the legal cardholder for this charge card, and that I am legally authorized to enter into this one-time or recurring billing agreement with AMARC Enterprises Inc.
Signature of Card Holder
To process and verify your identity we will need you to Provide Photocopy of Driver’s License and Front & Back of Credit card
Drop files here or

Max. file size: 50 MB.

Save and Continue Later

Business Information