COMPANY INFORMATION:

Company’s Legal Name*
Company’s DBA/Trade Names (If Any)*
Company Address
Company City

Company State —Please choose an option—ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Company ZIP Code
Company Email Address*
Company Phone Number*
Entity Type —Please choose an option—CorporationLimited Liability CompanyLimited PartnershipPartnershipSole ProprietorshipOther
State of Incorporation/Organization —Please choose an option—ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
EIN/Tax ID

PRIMARY CONTACT PERSON:
First Name
Last Name
Position at Company
Email Address

1. Please identify the URL for your own proprietary website(s) where you intend to sell HomeoPet Products.*

Please note that you are only permitted to sell the Products online through a Permissible Public Website, which is a website that:
(i) is operated by you in your own legal or registered fictitious name
(ii) clearly states your legal name or registered fictitious name and contact information,
(iii) does not give the appearance that it is operated by HomeoPet or any third party,
(iv) has been registered with HomeoPet through this form, and
(v) is operated in compliance with the HomeoPet Online Sales Guidelines, set forth below

Consent to sell the Products on online marketplaces is not granted through this form.
HomeoPet reserves the right to terminate, at any time and in its sole discretion, its approval for Retailer to market and sell Products on Permissible Public Websites authorized through the Form.

2. From which sources, including HomeoPet distributor(s), do you purchase HomeoPet Products?*

By checking this box, I agree, on behalf of Retailer, as follows:
1. Retailer acknowledges and agrees that it will abide by the Retailer Policy.
2. Retailer affirms that the information provided in this Form is true, accurate, and current.