Home › Pharmaceutical Representative Application

Resources

Login here

Pharmaceutical Representative/Vendor Application for Admission to Facility

Pharmaceutical Representative/Vendor Information

 

Representative Name
Representative Address
Representative Phone Number
Representative Email

Pharmaceutical/Vendor Company Information


Company Name
Company Address
Company Phone Number
Company Specialty

Representative Manager/Supervisor Contact Information


Manager/Supervisor Name
Manager/Supervisor Address
Manager/Supervisor Phone Number

It is understood that while the representative is on the Wheaton Eye clinic premises, he/she shall hold harmless and indemnify Wheaton Eye Clinic from any and all liability which could be incurred while on the premises. This relationship may be terminated by Wheaton Eye Clinic, Ltd. at any time upon written notice.


I understand the Wheaton Eye Clinic Pharmaceutical/Vendor Representative Policy and I agree to market my products in accordance with the policies of Wheaton Eye Clinic, Ltd.