Partner & Healthcare Practitioner Application

Partnership Type - Please choose one *Partner - I would only like to share product links and receive commissions on sales I refer *Healthcare Practitioner (HCP) - I see clients 1:1 and I would like sell physical product in my office and/or drop ship to my clients *HCP Combination - I would like to do both of the above *Ambassador - I would like to promote Healthy Gut products to my audience *Distributor - I would like to sell Healthy Gut products in my brick and mortar store and/or ecommerce store *

First Name *

Last Name *

Email *

Who will be the primary contact for your account? (Please list their first & last name, along with their title within the company) (optional)

How did you hear about Healthy Gut? *

Country * AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis and FutunaWestern SaharaYemenZambiaZimbabwe

Address 1 *

City *

State *

Postcode *

Phone *

SMS Text Opt-In (optional)Yes (optional)No (optional)

Business or Practice Name *

Website *

How would you best describe your business? *Functional Medicine Practice *Health Coaching Practice *Health Enthusiast *Other *

What has you interested in partnering with Healthy Gut? *

Can you share a little bit more about who your clients and community are? *

Social Media Handles (optional)

Do you have a Health/Wellness Podcast? *Yes *No *

Preferred Communication (Please let us know your preference for communicating with you about your Healthy Gut account) *Email *Phone *SMS Text *

How will you share HG products? *1:1 Protocols *Website *Social Media *Blog / Newsletter *Other *

What is your licensure/certification? State NA if applicable *

License - Upload a copy of your active license (Allowed File Types: doc,docx,xls,xlsx,pdf,jpg,jpeg,png,gif,txt)

Tax ID *

Username *

Password *

Confirm password

Do you currently recommend or sell supplements as part of your care plans or protocols? If yes, which ones? *