Retail Application Form

Please note: Fields marked with a * are required

General Info
* Legal Company Name:
* Street Address:
* City:
* Province/State:
* Postal/Zip:
Billing Address (if different from above)
Street Address:
City:
Province/State:
Postal/Zip:
Shipping Address (if different from above)
Street Address:
City:
Province/State:
Postal/Zip:
Business Info
* Business Phone:
Business Fax:
* Business Email:
Business Website:
Date Business Started (dd/mm/yyyy):
Days & Hours of Operation:
Contact Person(s):
Which of the following best describes your business?
Doctor’s Office
Retail Store
Health Institute
Other (explain):
Are you currently selling other health appliances?
Yes No	If Yes, please list:

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DISCLAIMER

The information on this site is not meant to diagnose, treat or cure any disease. As well, the FDA or any other institution has not evaluated the information on this site unless otherwise stated. All the opinions and views expressed on this site come from the authors and are presented for educational purposes. You are responsible for your own health and for the choices you make regarding your health. It is also your responsibility to seek out the advice of a licensed healthcare practitioner if you require this.