DISTRIBUTOR APPLICATION FORM

DISTRIBUTOR APPLICATION FORM
*Name
Title
*Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
*Country
Work Phone
Fax
*E-mail
* Which best describes your type of business?
	Importer Distributor Wholesaler / Distributor Retailer Other
If other, please describe.

*In what countries, states, provinces or regions do you currently serve.

* What types of products do you currently sell? Please check all that apply.
	Cosmetics Skin Care Products Beauty Products Vitamins Herbal products All natural products Personal care products
*If our product works as stated and your customers like it, how many bottles do you estimate you could sell per month?

Include any specific questions in the box below.