Registeration - Derma Distributor

Register

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APD FOP Form

Download Payment Authorization Form

For secure and seamless transactions, please download and complete our Payment Authorization Form.
Once filled and signed, kindly email it to info@americanapd.com
to complete your account setup or process your payment authorization.

Download the Form

Send it on : info@americanapd.com

Business Type

DBA Name

Company Name

GLN Number

Shipping Information

Shipping Address

Shipping Suite

City

Checkboxes

Billing Information same as Shipping Information

State

ZIP Code

Billing Information

Billing Address

Billing Suite

City

State

ZIP Code

Contact Information

Phone

Fax

Ownership Information

Owner Name

Second Owner Name

NPI Number

Phone

City Phone Address

State Licenses Number

DEA Licenses Number

DEA License Upload

State License Upload

PIC Pharmacist License

Agreements

Checkbox (T & C)

I agree to the Terms and Conditions

Last updated: 2025-06-23

Checkbox

I consent to receive SMS messages. Msg & data rates may apply.

Signature Date

The registration form cannot be used because either a username or email field is required to process registrations. Please edit the form and add at least the email field. https://dermadistributor.com/wp-admin/users.php?page=wpum-registration-forms#/

Register

APD FOP Form

Download Payment Authorization Form

Download the Form

Shipping Information

Billing Information

Contact Information

Ownership Information

Agreements

Enjoyed traditional SPA

Company

Support & Resources

Social Media

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