First Name:       

    Last Name:        

    Company Name: 

    Kind of Business Entity:  (Please list Corporation, LLC, S Corp, Partnership, Sole-Proprietorship, etc.)

                                                                                              Sole Proprietorships are required to fax state resale license or registration

    Federal Tax ID # or Federal Employer ID#:    (Please do not submit your social security number)     

    State Resale #, State License or Registration #:    Mandatory. Sorry no exceptions.

    Street Address: 

    City: 

    State: 

    Zip Code: 

    Business Phone: 

    Home or Cell Phone: 

    Fax: 

    E-mail:    We're sorry, but we do not accept hotmail addresses.                                                 

    Web Site: 

    Do you want products with your logo on the label?  (Yes or No)   If no, all products will feature our name on the label!

    Please list the quantities of each product that you may wish to purchase: 

    Will you be packaging your own products?  (Yes or No). 

                      Do you currently manufacture or formulate skincare products? (Please answer yes or no, if you leave this area blank, we may not be able to assist you)

                      Please feel free to list any comments you have:

    How did you first hear about us? (Select One):   Web Search Referral Advertisement - Web Advertisement - Print Other (Please list below)  

    Search engine used: 

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