To be a Wholesaler - Life Rising

Practitioner

Practitioner Search ~ To be a Wholesaler

We supply Life Rising Formulas to all qualified health professionals, pharmacies and health food stores.

Wholesale Account Application (All * fields are required)

Date:* (MM/DD/YY)
Business Name:*
Business Address:*
City:*	State:*	Zip:*
Business Phone:*		Fax:*

Name of the main doctor or practitioner:
Name of contact person:*
Position:
Business Scope:*
Tax ID#:*		Resale Tax ID#:


Average Annual Sales:*
0-10,000 10,000-50,000 50,000-100,000
100,000-500,000 500,000-1,000,000 Over 1,000,000


Please list two business with their telephone number for reference:
1)		Tel:	Years
2)		Tel:	Years


How do you know us?*
a.** Referred by our current practitioner or patient:
b. From Magazine ad (please specify magazine):
c. From Show (please specify show)
d. Direct mailing
e. From Web Site
f. From TCM School lecture
g. Contacted by sales person (please specify name of the sale person)
h. Others

*Please send us a copy of your Business License and Certification*
Fax: 312-842-0626
Mail: Holicare LLC, 2131 S. Archer Ave. Suite B, Chicago IL 60616

office ~

7884 S. Quincy St Willowbrook, IL 60527

~ Phone: 630-654-0617

About Us ~ Product ~ Service ~ Practitioner ~ Education Opportunity ~ General Knowledge
~ Appointment ~ On-line Store ~ Site Map ~ Contact Us ~ Home

Copyright © 2003 Life Rising Corp. All rights reserved.