W1200 Bulk Registration

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Welcome to Haleon Consumer Healthcare’s Nicotine Replacement Therapy (NRT) Direct Purchase Program (Program) , administered by Arrowhead Promotion & Fulfillment. This Program is offered to qualified Buyers to directly purchase NRT in bulk case quantities to complement their smoking cessation initiatives.

To verify eligibility for the NRT Direct Purchase Program please answer the following questions.

Organization Qualification and Registration

(All fields marked with * are required)

* Organization is seeking NRT for a(n)

* NRT Purchases are intended for (check all that apply)

* Organization will provide NRT to participants at the following cost?

* Smoking Cessation Counseling will be provided

* NRT purchased will only be available to Organizations Smoking Cessation Program participants?

* NRT purchased will be used as part of a clinical trial?

* Organization agrees NO product purchased through the NRT Direct Purchase Program will be resold in retail, eCommerce, or mail order.

* Will you be using a credit card or purchase card for this NRT purchase?

Organization Information

* Organization Name

* Organization Website

* Organization Address Line 1

Organization Address Line 2

* Organization City

* Organization State

* Organization Zip

* Organization Phone

* First Name

* Last Name

* Email

* Title

* Office Phone

Mobile Phone

Sales Tax Exempt?

Upload a Picture of Your Sales Tax Exemption Certificate

Take a picture of your Sales Tax Exemption Certificate where it will be clearly visible and upload in the area indicated below.

Upload image

Image format must be JPG, PNG, GIF, or single-page PDF

#	File Name	Remove
1	No Image(s)

* Expiration Date

* I agree to the Terms and Conditions