Customer Information

Customer Contact

Contact Name*
Primary Contact
Purchasing Manager

Company Name and Address


Customer Type

Customer Type*
Only sign section below that applies to customer type selected

Consumer - Home Use

I certify that this IVD product purchased from CLIAwaived, Inc. will:

(1) Only be used for Consumer applications

(2) Not be altered in any way (including not adding or modifying any labeling and

(3) Not be re-sold

and I agree to give CLIAwaived, Inc. 30 days written notice in the event I intend to change this usage in the future.

Name
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Use your mouse or finger to draw your signature above
Please sign the above signature field prior to submitting. If unable to sign, by checking this box I acknowledge the above information and submission of this form constitutes an electronic signature

Professional Use Certification

I certify that IvD product labeled as "Professional Use Only" purchased from CLIAwaived, Inc. will:

(1) Be used by Professional Users only (ref: license/credential above)

(2) Not be altered in any way (including not adding or modifying any labeling and

(3) Not be resold

and I agree to give CLIAwaived, Inc. 30 days written notice in the event I intend to change this usage in the future.

Name
[clear]
Use your mouse or finger to draw your signature above
Please sign the above signature field prior to submitting. If unable to sign, by checking this box I acknowledge the above information and submission of this form constitutes an electronic signature

Forensic Certification

I certify that this IVD product labeled as "Forensic Use Only" purchased from CLIAwaived, Inc. will:

(1) Only be used for Forensic applications

(2) Not be altered in any way, including not adding or modifying any labeling

(3) Not be resold

and I agree to give CLIAwaived, Inc. 30 days written notice in the event I intend to change this usage in the future.

Name
[clear]
Use your mouse or finger to draw your signature above
Please sign the above signature field prior to submitting. If unable to sign, by checking this box I acknowledge the above information and submission of this form constitutes an electronic signature

Reseller Certification

I certify that this IVD product labeled as "Professional Use Only" purchased from CLIAwaived, Inc. will:

(1) Only be used for professional use

(2) Not be altered in any way, including not adding or modifying any labeling

and I agree to give CLIAwaived, Inc. 30 days written notice in the event I intend to change this usage in the future.

Name
[clear]
Use your mouse or finger to draw your signature above
Please sign the above signature field prior to submitting. If unable to sign, by checking this box I acknowledge the above information and submission of this form constitutes an electronic signature

Emergency Use (A device that is not FDA Cleared and not CLIA categorized) Certification

I certify that this IVD product labeled as "Emergency Use Authorization (EUA)" purchased from CLIAwaived, Inc. will:

(1) Only be used for applications within the scope of the Emergency Use Authorization

(2) Not be altered in any way (including not adding or modifying any labeling

(3) Not be resold

and I agree to give CLIAwaived, Inc. 30 days written notice in the event I intend to change this usage in the future.

Name
[clear]
Use your mouse or finger to draw your signature above
Please sign the above signature field prior to submitting. If unable to sign, by checking this box I acknowledge the above information and submission of this form constitutes an electronic signature

Facility Information

Does your facility currently have a laboratory license?
Which of the following best describes your business?*

Check all that apply
Product Interests*
Equipment currently in operation at your facility

Check all that apply
Please send me information on the following
Please check all that apply
Please send me emails with the following product specials and promotions
Check all that apply