Institutional Buyer Qualification — Live Well Research Supply

Thank you. Your qualification form has been submitted. Our compliance team will review your entity and respond to the institutional email provided within 48 hours. You will not be added to any retail lists.

Completing this form does not create a purchase obligation. We verify the entity and its regulatory standing before any order is processed. All information submitted is kept confidential.

Section A — Entity

Legal Name of Entity * Trade Name (if different) Registered Address *

Business / Tax ID *

Website

Entity Type *

Section B — Primary Contact

Full Name *

Title / Position *

Phone (with country code) *

Institutional Email *

Section C — Regulatory Standing

License / Registration Number

Issuing Authority

Section D — Intended Use

In-vitro laboratory research Analytical quality control Academic research Other (describe below)

Other (describe)

I confirm that all products will be used for research purposes only, are not for human or veterinary use, and will not be resold to individuals.

Section E — Products of Interest

Product	Strength	Estimated Annual Quantity	Research Application

Section F — Shipping & Billing

Institution Delivery Address * Billing Address (if different) Payment Method *

Bank Wire / TT Corporate Card Other (discussed after qualification)

Section G — Compliance Acknowledgments

I acknowledge that products supplied are for research use only, not for human or veterinary use. I acknowledge that products will not be resold to individuals. I acknowledge that the importer is responsible for compliance with local import laws. I acknowledge that shipping declarations will be truthful and values will not be understated. I acknowledge that records of these transactions will be retained for compliance purposes.

Section H — Signature

Printed Name *

Title *

Signature (type full legal name) *

Date *

LIVE WELL RESEARCH SUPPLY