Dear Supervita customer,
***New Vasopro & Ephedrine Plus*** customers please be sure you fill out the registration form via our website and fax, scan & email or mail back to us for our records. You will only be required to fill this form out once unless regulations change.
The personal information you provide is for our internal use only. Your information will be kept absolutely confidential and handled responsibly. It will not be given, sold or lend to any third-party organizations.
"False statements or misrepresentations may subject the purchaser to criminal penalties under section 1001 of title 18, United States Code, which may result in a fine and/or imprisonment for not more than five years."
If you have any questions with this form, please call 215-620-7776 or email to
firstname.lastname@example.org Monday-Friday, 8:00 am - 4:00 pm EST
Ephedrine hcl Order Requirements
This form must be filled out for Ephedrine hcl customers. After this form has been received by Supervita.com and it is on file, you won't be required to submit again
unless regulations change. Please fill out this form in its entirety. If any information is missing, your order cannot be processed.
Please choose one of the following to submit this form.
Fax: (267) 282-5356
Email: email@example.com. Scan (with drivers license attached) or take a digital photo
Mail: this form to Supervita.com E-Registration
217 Willow Drive, Warminster, Pa 18974-3744
Current Address ____________________________________________
City ___________________ State ____________ Zip _____________
Date of Birth ____/____/____
Phone Number ______________________
Signature ________________________________ Date _____________
(Signature is mandatory) Please tape or glue a copy of your Driver's License/State ID card here. (Must match your current address) The personal information you provide is for our internal use only. Your information will be kept absolutely confidential and handled responsibly. It will not be given, sold or lend to any third-party organizations.