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Please fill out the following fields accurately with your information
This is a preliminary application and contractually binds you and us in no way whatsoever
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| Address 2 : |
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| State: |
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| Code/Zip: |
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If your application is successful the following area code and phone number would be the number displayed for the general public to contact you as a distributor for their area. |
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Fax: |
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Msn: |
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Yahoo: |
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| Do you have previous sales experience? |
Yes |
No |
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Internet |
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Home Sales |
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TV Shopping |
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Retail (Your own stores) |
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Commercially (To retail outlets) |
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Neighbour Hood (Zip area) |
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City |
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State* |
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Country* |
| Please specify geographical area named above |
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| Which distributor status are you applying for? |
Independent Distributor |
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Exclusive Distributor |
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* Please note: Country and State geographical regions will only be considered if the persons or businesses is fully able to effectively maintain the total region or area that is applied for! |
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Please give a brief description of yourself or your company and any other information you feel maybe relevant to this application in the box below |
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