- MantraMeds

MantraMeds Insider Program
Please read the application guidelines and submit all completed materials as carefully as possible, so there will be unnecessary delays. We are looking forward to your application, as as a note please be aware that qualifications for the program may change due to company needs, market concerns or industry changes.

Now, let's get onto the form!

Please fill in all applicable information the * notes required information.

Personal Information

First Name*:

Last Name*:

Phone*:

Your Email Address*:

Note: If you already have an account with us make sure you use the same email address that you use to login to our website.

Group or Business*:

Job Title:

Years on the Job:

Alternate Employment Example
(Describe in less than 200 characters)

Top Size

Bottom Size

Birthday:

Interests, Activities, Sports or Hobbies
(Describe in less than 200 characters)

Why do you want to become a MantraMeds Insider?*
(Describe in less than 200 characters)

Tell us something quirky about yourself (don't worry, we won't put this up on Facebook)*

Please let us know how you would like to participate in the program (Check all that apply)

Focus Groups
Product Development
Educational Outreach
Surveys
Selling for Profit Opportunities (Hospital Sales
Group Sales)
None of the above I just like the product and want to help spread the word

How did you hear about the program

If Other, Please Specify

How Do You Prefer We Contact You*

Account Information

Do you already have an account with us?

Billing Information
Address*:
Address (Line 2):
City*:
State*:
Country*:
Zip Code*:
Shipping Information
	Same as Billing Information
Address*:
Address (Line 2):
City*:
State*:
Country*:
Zip Code*:

Program Terms and Conditions

Your e-mail address must be valid. We will send periodic emails with information about MantraMeds Insider Program or other promotional offers and news. No spam.

We respect your privacy. Email addresses are not released to third parties. Instructions for removal come with every email.

By completing this application you acknowledge the responsibility that comes with the special pricing and privileges Mantra offers you as an industry professional. Membership is valid for one (1) year from application date. You will be asked to renew your membership at the conclusion of this period.

If you are applying as an individual, the products received through this program are for you and you alone. Period. Any purchases for people other than you can result in immediate dismissal from the program. We count on your integrity to follow these parameters. Abuse in any form will not be tolerated.

If abuse is suspected, we will investigate to the best of our ability and offenders will be removed immediately from the program. We respect the work you do as a healthcare professional, and we hope you understand and respect how seriously we take this program. We look forward to having you enjoy the many benefits we offer and having you as a part of our team.