Application for Authorized Customer Account First Name Last Name Phone NPI License Number Business Name Business Address Business Phone Business TypeBusiness Type 1Business Type 2Business Type 3NPI File UploadUpload NPI File Upload UploadE-mail Address By submitting this application, I verify that I understand Vivere Biologics distributes products for further manufacturing or research use only (ROU) and hereby acknowledge that this product will not be used for further manufacturing or in a clinical setting, and I hereby waive any claims of any damages of any kind and hold harmless Vivere Biologics and its original manufacturer should I use this product for any other purpose. Only fill in if you are not human Studio Location 749 Goldfield Ave. Santa Monica, CA Write Me robert@robertortega.com 415-509-6998