Authorized Reseller Website Registration Form

If you purchase DermaRite Industries LLC (“DermaRite”) products from a DermaRite Authorized Distributor for purposes of resale to end-user customers and wish to sell DermaRite products on your own proprietary website, you must register your website with DermaRite. Please note you are not authorized to sell DermaRite products on or through your own proprietary website until you have registered that website with DermaRite using this form.

To complete registration, please review the DermaRite Industries LLC Authorized Reseller Policy for the United States (“Authorized Reseller Policy”), including the attached Online Sales Guidelines, fill out the DermaRite Industries LLC Authorized Reseller Website Registration Form (“Form”) below, agree to the Legal Agreement, and click SUBMIT.

This Form is only used to register “Permissible Public Websites,” as defined in the Authorized Reseller Policy. The Authorized Reseller Policy prohibits you from selling DermaRite products on online marketplaces (such as Amazon, eBay, and Walmart Marketplace) without DermaRite’s prior written consent. Consent to sell DermaRite products on online marketplaces is not granted through this website registration process.

This website registration process and the Authorized Reseller Policy are applicable only in the United States of America.

* Fields marked with an asterisk are required.

    COMPANY INFORMATION:

    COMPANY’S LEGAL NAME*

    COMPANY’S DBA/TRADE NAMES (IF ANY)*

    COMPANY ADDRESS*

    COMPANY ADDRESS 2

    COMPANY CITY*

    COMPANY STATE*

    COMPANY ZIP CODE*

    COMPANY EMAIL ADDRESS*

    COMPANY PHONE NUMBER*

    ENTITY TYPE*

    STATE OF INCORPORATION/ORGANIZATION*

    EIN/TAX ID* –

    PRIMARY CONTACT PERSON:

    FIRST NAME*

    LAST NAME*

    POSITION AT COMPANY*

    EMAIL ADDRESS*

    PHONE NUMBER*

    1. DO YOU SELL OR INTEND TO SELL DERMARITE PRODUCTS AT ANY BRICK-AND-MORTAR RETAIL LOCATIONS?*

    PLEASE IDENTIFY THE PHYSICAL ADDRESS FOR EACH BRICK-AND-MORTAR LOCATION WHERE YOU SELL OR INTEND TO SELL DERMARITE PRODUCTS.

    2. PLEASE IDENTIFY THE URL FOR EACH WEBSITE WHERE YOU INTEND TO SELL DERMARITE PRODUCTS.*

    Please review the restrictions on online sales in the Authorized Reseller Policy carefully. Please note that you are only permitted to sell the Products on “Permissible Public Websites,” as defined in the Authorized Reseller Policy. Consent to sell DermaRite products on online marketplaces is not granted through this website registration process.

    3. FROM WHICH AUTHORIZED DISTRIBUTOR(S) DO YOU PURCHASE DERMARITE PRODUCTS?*

    4. DO YOU STORE OR INTEND TO STORE YOUR INVENTORY OF DERMARITE PRODUCTS AT A LOCATION OTHER THAN THE COMPANY ADDRESS IDENTIFIED ABOVE?*

    PLEASE PROVIDE THE ADDRESS FOR ALL LOCATIONS WHERE YOUR INVENTORY IS STORED OR WILL BE STORED.

    5. DO YOU INTEND TO USE ANY THIRD-PARTY FULFILLMENT SERVICE (INCLUDING DROP-SHIPMENT BY AN AUTHORIZED DISTRIBUTOR) TO FULFILL ORDERS FOR DERMARITE PRODUCTS PLACED THROUGH THE WEBSITE(S) IDENTIFIED IN QUESTION 2 ABOVE?*

    PLEASE IDENTIFY THE NAME OF THE FULFILLMENT SERVICE AND DESCRIBE THE SERVICES PROVIDED.

    LEGAL AGREEMENT

    By checking this box, I agree, on behalf of Reseller, as follows:

    1. Reseller acknowledges and agrees that it will abide by the DermaRite Industries LLC Authorized Reseller Policy for the United States.

    2. Reseller understands that it is strictly prohibited from using DermaRite’s brands, names, logos, trademarks, service marks, trade dress, copyrights, and other intellectual property in any way other than as granted in the Authorized Reseller Policy without DermaRite’s express prior written consent.

    3. Reseller affirms that the information provided in this Form is true, accurate, and current.

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