Application for My Refillery Location

Thank you for your interest in My Refillery. Please take the time to fill out all the questions as only completed applications will be considered.

Question Title

* 1. What is your first name?

Question Title

* 2. What is your last name?

Question Title

* 3. Your street address?

Question Title

* 4. Postal Code

Question Title

* 5. What email address would you like to be contacted at?

Question Title

* 6. What city are you interested in opening My Refillery?

Question Title

* 7. On a scale of 1 to 5, how familiar are you with the zero waste movement?

Question Title

* 8. What things do you currently do to promote less waste in your home? (Click all that apply)

T