Wholesale Application Form Please Send Your Application by Fax or Mail to: BC Organic Herbs Ltd. 6471 Vernon Avenue Peachland, British Columbia Canada  V0H 1X8 Tel / Fax: +1 250 767 6650 * Required Info:   * Personal Name of Applicant:    _______________________________________________________________   Birthdate:     * Month: ________________________   Day:________  Year: ___________ * Place of Birth: * SS#:   _________________________________ _________________________________  * Business Name: * Tax ID:   _________________________________ _________________________________   Mailing Address:   * Street or PO Box:     ____________________________________________________________  * City: * Province/State:   _________________________________ _________________________________ * Country: * Postal/Zip:   _________________________________ _________________________________ * Business Phone: Home or Cell Phone:   _________________________________ _________________________________ * Email:   Fax:   _________________________________ _________________________________ * Business Class: * Business Type:   Individual Proprietorship Partnership Company  Retail Wholesale Distributor Company Direct Sales Ecommerce       Other major vitamin/health food products currently being carried?    ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________   Geographical area covered by your current marketing?    ______________________________________________________________ ______________________________________________________________   How did you first learn about Super Naturals Heart Formula?      ______________________________________________________________ ______________________________________________________________   Please provide 2 references (name/address/personal contact/phone number)    ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________   What are the main reasons in your decision to market Super Naturals Heart Formula?   ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________       Please be confident that we will never give or sell any of your information provided by this form. It will be used only to contact you if requested. Your security and privacy is protected.