DEALER / DISTRIBUTOR APPLICATION

Date:____________

Name: ____________________________________

Address:___________________________________

City:______________  State:_______ Zip:________

E-Mail:________________   Phone:_____________

Planned Usage:

Do you plan to use the product for personal use?                                                                  Yes      No       Maybe

Do you plan to resell the products to family/friends?                                                            Yes      No       Maybe

Do you plan to resell the products to local chiropractors, doctors or clinics?                      Yes      No       Maybe

Do you plan to resell to retail outlets such as health food stores, pharmacies etc.?           Yes      No       Maybe

One case equals 12 units of any single product or mix and match.

How many cases per year will you use or sell?                                                                      0-2     3-6     6-12     12+

Email to:  scott@herbalorganix.com