apply for a professional account

Please submit all applicable fields of this form to ensure proper set up of your account.

A copy of your practicing license and/or business license is required to complete application. Send license copies to A PDF version of this application is also accepted via email or mail and can be downloaded here.

Feel free to contact us with any questions about your application or account.

Shipping Address *
Shipping Address
Billing Address (if different)
Billing Address (if different)
Phone *
Practice Type *
Check all that apply
Please contact the credit department at Eclectic Institute for Net 30 application: 800-332-4372