Register
Register for Promotions below. All fields marked "*" are required.
Your Professional Information
First Name:*
Middle Name:
Last Name:*
Phone Number:*
Phone Ext:
Fax Number:
Cell Number:
Address:*   No P.O.Box
Address 2:   No P.O.Box
City:*
State:*
Zip:*
Designation:*
Specialty:*
Promotion Code:
 
State License No:*   DEA License No:  
State:*  

Address Info is same as Professional Info
Medical School*     DEA Address:
Graduation Year:*     City:
Affiliated Hospital:     State:
      Zip:
Your Account Information
Username:*
(Your Email)
  Info Passwords and PINs must be at least 8 characters using at least one number and at least one letter. Identical Passwords and PINs are not permitted.
Password:*  Info   PIN:* Info 
Verify Password:*  Info   Verify PIN:* Info 
Your eSignature
Electronic Signature

Your electronic signature or digital signature is required when requesting drug samples offered MySampleCloset.com® website and mobile application in order to comply with the provisions of the Prescription Drug Marketing Act ("PDMA").

As per 21 CFR Part 11, your electronic signature constitutes the unique combination of userID, password and PIN. This is personal to you and only for your use in order to request drug samples and product information on MySampleCloset.com® website. For the MySampleCloset.com® mobile application, your digital signature is your handwritten signature captured digitally and recorded in the form of pixels from your personal mobile device.

I certify that I am the person named above. I understand that the information presented above constitutes this electronic signature or digital signature, which is the legal equivalent of my hand written signature and will be accepted as same in a court of law, or before any federal or state regulatory agency with appropriate jurisdiction. I understand that it is illegal to have another person order and sign on my behalf to order drug samples.

I further certify that I am a licensed practitioner with the proper federal and state authority to request these drug samples. These drug samples are requested for use in my medical practice for the benefit of my patients. I understand that it is illegal to sell, trade or barter any drug samples and/or drug coupons, and that I am prohibited by law from billing Medicaid or Medicare for free drug samples provided to me.
Your electronic signature is required when requesting drug samples offered on MySampleCloset.com™ in order to comply with the provisions of the Prescription Drug Marketing Act ("PDMA").

* I agree with the Signature and Terms.

* I agree with the Privacy Policy.

Preferred Method of Contact:*