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Address*

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

Phone

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Ownership/Officers:

Do You Want to Provide Company Officers Contact Info?*

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President Name

First Last

Present Phone

President Email

Vice President Name

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Vice President Phone

Vice President Email

CFO Name

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CFO Phone

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Important Contacts

Do You Have A Specific Purchasing Contact?*

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Purchasing Name

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Purchasing Phone

Purchasing Email

Accounts Payable Name

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Accounts Payable Phone

Accounts Payable Email

Sale Manager Name

First Last

Sales Manager Phone

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Marketing Manager Name

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Marketing Manager Phone

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Purchasing/Sales/Marketing Information

Primary Product Line*

Customer Base*

Distributors
Research Laboratories
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Other

Primary Customers Served*

Geographical Area Served

List Area Competitors:

Do you currently purchase serum from other suppliers?*

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No

If yes, what is your annual purchase amount?*

Who are your key suppliers of serum

Peak products of interest*

Anticipated annual purchases of Peak Products:*

Major Means of Promotion

Number of Outside Salesmen:

Number of Inside Telemarketers:

Application will be reviewed and a representative will be in contact within 48 hours

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Become a Distributor

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Company Information

Ownership/Officers:

Important Contacts

Purchasing/Sales/Marketing Information

Application will be reviewed and a representative will be in contact within 48 hours