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CardiOKare Application Form
 

Please fill out the following fields accurately with your information
This is a preliminary application and contractually binds you and us in no way whatsoever


Address 2 :
State:
Code/Zip:

If your application is successful the following area code and phone number would be the number displayed for the general public to contact you as a distributor for their area.

 
Fax:
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Retail (Your own stores)
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Neighbour Hood (Zip area)
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State*
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Please specify geographical area named above
Which distributor status are you applying for? Independent Distributor
Exclusive Distributor

* Please note: Country and State geographical regions will only be considered if the persons or businesses is fully able to effectively maintain the total region or area that is applied for!

Please give a brief description of yourself or your company and any other information you feel maybe relevant to this application in the box below
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