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Ultra-Balm New Distributor Application

 

  

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:    
(There is never an additional cost with referral.)

Number Of Sales People In Company:

CONTACT INFORMATION

Phone Number:  Fax Number: 

Physical Address: 

City:  State:  Zip Code: 

Email Address:   

Website:

Are you currently using Ultra-Balm?  

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:

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:  


                

 
Unauthorized use is a willful infringement upon rights under 17 U.S.C. Section 101 et seq.
You will be held liable for statutory damages as high as $150,000 for each occurrence as set forth in Section 504 (c)(2) therein.
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