EmailMe Form - Wholesale Account Application

Company Name *

Owner/s Name *

First Last

Main person authorized to order *

First Last

Billing Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Shipping Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone: *

### - ### - ####

Fax:

### - ### - ####

Email: *

Confirm:

Web Site:

Please Check:

I will provide copy of current resale/tax certificate. (If not available for upload please mail or fax.)

Our state does not require sales tax.

I will provide a copy of our state business license. (If not available for upload please mail or fax.)

Copy of resale/tax certificate:
pdf or jpeg

Copy of state business license:
pdf or jpeg

Wholesale Account Survey

This information will help us understand your business so that we may serve you better.

Contact Person: *

What type of business, store, shop or clinic do you operate? Or do you work from home? *

What kind of products are available in your store/business?

How long have you been in business?

What are your hours and days of operation? *

Do you offer a catalog of the products that you sell? *

YES

NO

Is anyone on staff trained in the use and application of flower essences and other vibrational remedies? *

YES

NO

If YES, please list the training received:

Do you ship products? *

YES

NO

If YES, where to?

Do you sell essences to therapists or practitioners *

YES

NO

If YES, do you offer a practitioner's discount? *

YES

NO

Our website features a Store Locator that uses Google Maps. Would you like your business added? We will add your location after your 1st purchase and maintain the listing as long as your account remains active. You can also choose to be listed on a non-interactive page on the site. *

Please include my business in the Store Locator.

Please list my business but not in the Store Locator.

Please don't list my business on your site.

One of the benefits of your wholesale account is a free subscription to our Online Repertory, also called the Living Book. If you are interested we will contact you with details. *

Yes, I am interested!

No thanks

Thank you!! Use this space for any other information that may help us to understand your business and serve you better.

Signature *

First Last

By signing this form you agree to abide by Alaskan Essences Wholesale Account Information and Terms. A copy of these terms were provided in the email you received with the link to this application.

Date Time *

MM / DD / YYYY HH : MM AM/PM