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* 1. Date

Date

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* 2. Legal Business Name

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* 3. First Name

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* 4. Last Name

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* 5. Federal EIN#

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* 6. Choose your industry

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* 7. Do you have a physical brick and mortar store that you intend to sell products in?

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* 8. Website/URL

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* 9. Phone Number

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* 10. Email

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* 11. Address

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* 12. How did you hear about us?

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* 13. Estimated yearly sales interest? (please use US dollars)

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* 14. Do you already sell homeopathic products or other health-related products?

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* 15. If you already sell similar products, please list a few of these products below.

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* 16. I agree and understand that I cannot sell this product online through an online store

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* 17. I consent to having this information submitted so the application can be reviewed

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* 18. signature

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* 19. When finished with this application, please go to https://www.irs.gov/pub/irs-pdf/fw9.pdf and complete a w9 form.  Please upload your W9 (to complete your application) 

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 20. Please attach your state Sales tax exemption or reseller certificate for your state.  Please make sure it has your State account/business number on it

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 21. Once approved you will receive a call or email from our team to set a meeting to explore your options and discuss how carrying our brand will increase your customer base

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