benaGene Wholesale Account RegistrationAlanCash2022-07-12T15:47:57-07:00

benaGene Wholesale Account Registration

To apply to become a benaGene wholesale partner, please fill out the form below. Our team will reply via email in 3 business days or less. Please call 858-947-5722 or email rbrown@benagene.com with any questions. Thank you for your interest in benaGene!

Practitioner Name *

First

Last

Professional Designation *

Company *

Billing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number *

Email Address *

Office Manager Name *

First

Last

Tax Resale Number

This field is required for account approval if you are a medical professional based in California.

Is your shipping address different from the billing address above? *

Yes
No

Shipping Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Completion of this form indicates an agreement to abide by the terms of our Minimum Advertising Pricing (MAP) Policy. *

I agree.
I do not agree.

Our MAP Policy is available for review here.

Questions? Feel free to submit them with this form!

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