Authorized reseller application
Company background information
Legal business name
Address
City
State
Postal code
Country
Company telephone
Company fax
Company website
Principal
Chief Financial Officer
Marketing manager
Primary contact name
Address
City
State
Postal code
Country
Contact telephone
Contact fax
Contact email
Purchasing agent
Type of company
Federal tax ID #
Geographic areas served
Please indicate all geographic areas served (describe with as much detail as necessary includding cities, provinces, international regions, etc.):
Do you intend to export any Metabolic Nutrition products?
 Yes    No
If yes, please specify:
Applicant specifications
Number of facilities/offices Total number of employees Approximate annual revenue
Does your company sell any product via the Internet?
 Yes    No
If yes, what percentage of sales come from the Internet?
Does your company sell products via mail order?
 Yes    No
If yes, what percentage of sales come from mail order?
How many years in business? Indicate any extenuating circumstances (new ownership, etc.)
 
Which products are you interested in representing?
 All products
 Ametrol  CGP  Doctor's calcium  Hydravax  Lipovent  Oxlin  Phenolox  Protizyme
 Quidprim  SyneDrex  TAG  Thyrene
What other manufacturers' products do you carry?
Other than nutraceuticals, what products do you sell?
Describe store location (stand-alone, boutique, strip mall, etc.):
Describe store appearance and please provide photos of store front, merchandise layout, register, and service areas: