* First Name:
* Last Name:
* Address - Line 1:
Address - Line 2:
* City:
* Province/State:
* Postal, or Zip Code:
* Telephone:
* Email:
(self-employed, proprietorship, partnership, corporation, if other - specify)
Retail Outlet:
(Own, Lease, Manage;
if other - specify)

How long have you been in business?
Name of owner(s):
Main Contact:
Payment Preference:
NOTE: If you choose Net-30 Term, you will be asked to complete and return a credit application, which will be sent to you. Until approved, pre-payment will be required.
QUESTION 01: Have you sold, or are you selling, any massage devices/machines? Which ones?
QUESTION 02: If a teacher/practitioner/school, what classes/techniques? Also, number of students/clients per year?
Your questions / comments: