New Retail Account Application

The new you starts today

Please provide the following information for wholesale prices and further product information.

We also accept applications via fax. Please print this application and fax to the following number.
Fax: (310) 783-0243

Business Name *
Type of Business * Retail Store
Health Practitioner
Beautician
Online
Company Website
Contact Person *
Billing Address *
City *
State *
Zip *
Telephone Number *
Fax Number
Email *
Seller's Permit No. / Fed ID
Shipping Address   Same as billing address
Address
City
State
Zip
Comments