Samson Brands -- We Make Healthy Living Easy

Dear Samson Brands Dealer Applicant,

Thank you for your interest in the Samson Brand Product Line.

Samson Brands. is committed to the success of each of our authorized dealers. Through you, we provide your customers with quality products that will give years of dependable service and lasting value. As an Authorized Dealer we can provide you with services such as:

Provide you with extra brochures, posters, videos, etc. of the Samson products as needed.
Provide you with the right to use our Registered Trademark pictures, logos, etc. These can be sent to you directly from our head office, or can be taken from our website.
Refer potential customers to your location if they are in your area.

We look forward to providing the best possible service for you and your customers.

Regards,

Everyone at Samson Brands

*All fields are required*

Legal Company Name:

Street Address:

City:

State:

Zip:

Billing Address:

(if different from above)

Shipping Address:

(if different from above)

Business Phone:

Toll Free:

Business Fax:

Would you prefer the weekly referral list faxed? Yes No

Business Email:

Would you prefer the weekly referral list e-mailed? Yes No

Business Website:

Will the Samson be sold at this website? Yes No

Date Business Started:

Days & Hours of Operation:

Who will be the buying or contact person(s):

Name and contact info of the company owner:

If more than one name listed above are you operating as:
Partner Corporation State where incorporated

Which of the following best describes your business:

Wholesaler Retail Store Catalog House Chiropractor
Doctor Office Health Institute Home Business* Internet Dealer
Other (explain):

*We cannot refer potential customers to your location.

Are you currently purchasing products from other manufacturers / distributors?
Yes No

Please list distributor information below:

Name:		Name:
How Long:		How Long:
Phone:		Phone:
Address Line 1:		Address Line 1:
Address Line 2:		Address Line 2:

(This information may be used for future reference when considering credit terms. Credit terms are reserved for clients making larger, regular orders.)

Are you currently purchasing the Green Power from other distributors?
Yes No

Please list distributor information below:

Name:		Name:
How Long:		How Long:
Phone:		Phone:
Address Line 1:		Address Line 1:
Address Line 2:		Address Line 2:

(This information may be used for future reference when considering credit terms.
Credit terms are reserved for clients making larger, regular orders.)

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