RESELLER Application

Name*
Prefix First Last Suffix
Phone*
Office
Email*
Website
Check at least one:*
- Health Care Practitioner
- Health Food Store
- Hospital
- Other
Please Elaborate:
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- Shipping address is the same
Shipping Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Type*
- Sole Proprietorship
- Partnership (Gen, LTD, LLC)
- Corporation
SS# (if Sole Proprietorship)
State/Province of Partnership/Corporation
VAT ID#*
All information provided by you and contained herein will be used for internal purposes only unless otherwise authorized by you in writing. By signing, you warrant that the information provided by you is true and correct and authorize Spectrum Supplements Inc. and it's agents to verify the information provided by you. A faxed copy of this application shall have the full force and effect of an original. Spectrum Supplements, Inc. reserves the right to deny any applicant at it's discretion.
Brand Names and/or products of interest (include Brands and products not currently offered)*
Authorized Signature*
Type your legal name to sign the document.
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