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Wholesale Account
Information
Thank you for your
inquiry! If you would like to purchase Mother Earth Products for Resale or
therapeutic use, contact us by;
:
E-MAIL
ContactUs@MotherEarthPillows.com
7
FAX
636-282-9517
… print this
form, fill in information and fax
'
PHONE
Call
800-344-2072
636-296-6100 with your information and order
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MAIL
Fill in this form, mail to: Mother Earth Pillows®
2085 Jennemann Lane,
Suite E
Arnold, MO 63010
We will then direct you to Mother
Earth Pillows® wholesale link. We look forward to hearing from you!
þ
Please complete all of the form;
Your name and
position ______________________________________________________
Today’s date __________________________
Business Name
_____________________________________________________ or Professional
License #_________________________
Address
(shipping)
___________________________________________ Address
(Bill
to)
_______________________________________
City
_______________________________ State _______ ZIP+4
______________
Telephone #
_______________________ Second Phone # _______________________ Fax #
_____________________
Sales Tax #
________________________ OR
Non-profit # ________________________ Please attach copy
Business category:
___Hospital
Integrative Health ___Hospital
(Department-_____________________) ___Clinic (type- ____________________)
___Healthcare Practitioner ___Home Health Store
/ DME / Pharmacy
___Beauty Industry
___Massage Therapist ___Chiropractor
___Gift Shop
___Spa/Wellness ___Website
___Catalog
___Other _________________________
Reason for purchasing; To Sell Retail ___ Use in treatment /
therapy ___ Clients or Patients to try ___ Personal ___
other
______________________________________________________________________________________________________
We offer a FREE
listing on our Website locater map for accounts offering Mother Earth
Pillows® for re-sale to the general public. An extended listing is
available for a one-time charge of $60 for as long as you are ordering our
products.
You have my permission to list my Retail address FREE Yes____ NO____
signed ________________________________
I want an extended listing, bill my account $60 Yes____
signed_________________________
(we
will contact you for your info)
Business contact
e-mail________________________________ Your Website
__________________________________
How did you hear
about our products?
Client/patient
____
Website ____ Ours or
another? ___________________________________
Personal Contact ____ Name of
individual ___________________________________
Staff member ____
Magazine Ad ____ Please note
name of magazine _________________________
Product Directory ____ Please
mention which one _____________________________
Conference/Trade Show ____ Please note name
or city ______________________________
Contacted me by
with the wholesale website; email
_________________________________________________
phone _______________________ or fax ______________________
We look forward to a beneficial and long business relationship! Please let
us know how we can provide you with the products you are looking for!
Karen
Kowal,
RN,
LMT, NCTMB, President/CEO
© 2005 Mother Earth
Pillows® All-Natural Pain Management since 1995 Made with Care in the USA
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