Distributor Application
Thank you for your interest in becoming a Distributor of our products! When you've finished filling out this form, press "Submit" and your application will be sent to us for review. You must be sure to include your email address and a phone number so that we can contact you! Fields marked with a * are required.

If you're interested in reviewing our products, we strongly suggest you order our Distributor Starter Kit. Click here for more information.

Your Company Information
*Email:
*Password: (Your password will be used to access the online ordering system. Your password must be no more than 8 characters and is case sensitive. )
*First Name:
*Last Name:
Company Name:
*Address:
*City/State/Postal:
*Country:	U.S. Canada France Germany Great Britain (UK) Mexico Netherlands New Zealand Puerto Rico (US) Taiwan United Kingdom
*Day Phone:
Night Phone:
Cell Phone:
Fax:
*Corporate Tax ID:	(or SSN)
Website URL:
*Products you are interested in distributing:	Nukkles Tinglers Botanical Fresh Quiklet
*How will you sell our products?  (e.g. mall cart, store, salon, etc.)
*How long have you been in business?	How Long? Just Starting Up Less Than 1 Year 1-2 Years 3-5 Years More Than 5 Years
*Realistically, how many Nukkles, Tinglers, Botanical Fresh and/or Quiklet units do you expect to sell per month?	How Many? 1-2 Dozen 3-12 Dozen 13-24 Dozen More than 24 Dozen
How did you hear about us?
	Nukkles Package Trade Show Advertisement Web Search Word of Mouth Other

After your application has been approved, your Distributor ID will be mailed to you along with a pricing schedule and online ordering instructions.