Email Address

Legal Business Name

Retail Business Name (If Different From Legal Name)

Retail Business Address

City

State/Province

Zip

Country

Company Principal Owner

Contact First Name

Contact Last Name

Contact Phone

Website(s) (Please List All Websites Where You Plan to Sell Products)

Year Your Company Was Established

Total Revenue Last Year

Percentage of Business Sold Online

Percentage of Business Sold In-store or In-clinic

Percent Sold Other (please explain)

Do you currently sell nutritional products under different seller names online? If so, please provide company name(s) and associated website addresses

Do you have multiple stores or clinics that will be selling Health & Wellness Associates, Inc? Do you have multiple stores or clinics that will be selling Health & Wellness Associates, Inc?NoneYesNo

Do you or any of your affiliated companies currently sell on eBay? (sales on Ebay are strictly prohibited) Do you or any of your affiliated companies currently sell on eBay? (sales on Ebay are strictly prohibited)NoneYesNo

Do you or any of your affiliated companies currently sell on Amazon Marketplace? (sales on Amazon are strictly prohibited) Do you or any of your affiliated companies currently sell on Amazon Marketplace? (sales on Amazon are strictly prohibited)NoneYesNo

If you are a healthcare practitioner please explain your specialty/licensure

How did you hear about Health & Wellness Associates, Inc?

Have you used Health & Wellness Associates, Inc in the past? Have you used Health & Wellness Associates, Inc in the past?NoneYesNo

Briefly describe your business, the products you are interested in selling, and how they can benefit your customers

All distributor applicants are required to provide at least three (3) professional references. Other nutritional supplement companies are preferred. Please include contact names and telephone numbers