Please fill out this form completely, BOLD fields are required!(DO NOT HIT RETURN - THIS WILL SEND THE FORM!)
Date:
Company Name: (If none please skip)
Authorized Buyer:
Referred By, If Any: NONE Internet Promotion Jessica Avila Ray & Claire Baker Vicki Basar Lisa Bass Melissa Bater Elizabeth Chu Mary Jo Clancy Katrina Davalos / Arizona Becky Eisenman Michael Farris Alice Fitzgerald Dave & Golda Griselda Joy & Daniel Hagenhoff Darlene Hitch Bruce Johnson Larry Kaplan N. David Kollander Tenzinz Limbu / Canada Brandi Higaki / Hawaii Merry Lou Ron McKee Popeye Merrifield Brandi Nichols Deedee O'Malley Gonzalo Vera Ortiz Sandy Petrila Pik-A-Tee Plus, Inc. Scott Reed Shelley Rinehard Sabastian Rodriguez Kate Ryan Mark & Sue Strasser Linda Torres Rhonda Weiand Bob & Barbara Williamson JoLynn Wright (There is never an additional cost with referral.)
Number Of Sales People In Company: 0 - 3 4 - 6 7 - 10 11 - 20 21 - 50 50 - 75 76 - 100 100+
CONTACT INFORMATION
Phone Number: Fax Number:
Physical Address:
City: State: Zip Code:
Email Address:
Website:
Are you currently using Ultra-Balm? No Yes!
Do you have any previous distributing experience (when & what product or product line) where (city/state):
Are you currently distributing any other products? If so what and where (city, state, zip) and how (at retail shows, tradeshows, stores or home sales):
Are you or have you ever sold demonstration products (when, where and what):
Number of Years Distributing: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+
Where and how would you like to distribute Ultra-Balm (include markets, city/state/zip codes)?
Additional Comments:
Thank you for completing our application and we appreciate your interest in our products. Expect a call from us shortly to explore your future with Ultra Balm!
When is the best time to contact you: Early Morning: 5AM - 8AM Morning: 8AM - 11AM Mid-Day: 11AM - 1PM Afternoon: 1PM - 5PM Evening: 6PM - 9PM