PROFESSIONAL REGISTRATION FORM

Please note: Registrants must be certified or licensed health care practitioners.

Thank you for your interest in joining our Professional Division. Once we have received your documentation and it has been approved, allow 48 hours for your account to be activated. You will be notified via email with a personal password for the Professional Division where you will have access to all our educational materials, webinar information, and a wholesale price list.

Please Note: (*) = Required Fields

First Name (*)

Last Name (*)

Address (*)

Address

City (*)

State (*)
Zip (*)

Tel (*)

Fax

Email Address (*)

State of Registration

Your Specialty

How did you hear about us? (*)

Internet SearchMagazineReferralSales RepSeminar

Who were you referred by:

Please upload your license or credentials below or you may email to: (pdf format):

You may also email or fax your documentation -

Fax: 631-477-6695 or email: info@epsce.com

For security purpose, please answer the following quiz: