Corporate Name*

DBA/Product Line Brand Name(s)*

State of Incorporation*
ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

In Good Standing with Secretary of State*
YesNo

Do you hold a City/County business license?*
YesNo

Time in Business (Years/Months)*

Do you have E&O/Product Liability Insurance?*
YesNo

Carrier Name:*

Policy Limit:*

Address*

CEO/Principal First Name*

CEO/Principal Last Name*

CEO/Principal Email*

CEO/Principal Phone Number

Number of Employees

Approximate Sales Revenue (Past 12 Months)

Primary Website*

Alternate Website*

About Your Product:

Are you currently manufacturing your own products, using 3rd party manufacturers, or both?
Own3rd PartyBoth

Is your hemp biomass and oil domestically sourced, or internationally sourced?
DomesticInternationalBothDon't Know

Are refunds offered if the consumer is unsatisfied with the product, if so how?
YesNo

How?

Does a product purchase enroll consumers in any ongoing, weekly or monthly automated billing and shipping?
YesNo

If Yes, describe the program and where a consumer can opt-out:

Do you warrant that all CBD or other products have been lab tested and comply with THC maximum content of under .3% THC?
YesNo

List lab(s) used:

Do you warrant that all CBD or other products have been lab tested and contain the advertised amount of CBD or other advertised active ingredient(s), if added as an isolate to enhance full or broad spectrum hemp oil?
YesNo

List lab(s) used:

Have you received any correspondence from any government agency concerning compliance with your business practices?*
YesNo

I attest and warrant that the information I provided above is accurate and correct, and indemnify PuraPhy LLC for any misrepresentations or unsubstantiated claims I make about my products, should I execute an Advertiser Agreement.

Submission of this form will be my digital signature. I understand I will have opportunity to amend my responses above prior to the execution of an Advertiser Agreement.

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