OreVital Dealer Application Form

Business Information

Business Name: Primary Contact Name: Email Address: Phone Number: Business Address: Business Type: Brick & Mortar Virtual Reseller Both Years in Business: Business Structure: Incorporated (LLC, S-Corp, C-Corp) Sole Proprietor Other Number of Staff:

Sales & Inventory Information

Expected Monthly Product Sales Range: $500 – $1,000 $1,000 – $5,000 $5,000 – $10,000 $10,000+ Do you currently sell similar products? Yes No Do you have a Resale Certificate or Sales Tax ID? Yes No Tell Us More About Your Business: I certify that the information provided is accurate and complete. Submit Application