The Natural Way Application Form Accredited Distributor

The Natural Way Weight Loss Clinics Australia

To help us assess how a The Natural Way Accredited Distributorship can meet your business needs, and to assess your suitability as a distributor, we ask you to please tell us a little about yourself.
All information will be treated in confidence.

Send to The Natural Way Head Office
Note:	Input fields marked * are REQUIRED fields
Personal Details
Full Name:	*
Street Address:	*
Suburb / Town:	*
State:	* Postcode: *
Telephone - Home:	*
Mobile:	*
Email Address:	*
Date of Birth:
Business Details
Current business name:	*
ABN:	*
Street Address:	*
Suburb / Town:	*
State and Postcode:	* Postcode: *
Telephone (incl area code):	*
FAX:
Business Web Address: (please do not include "http://" just begin with "www.")
Describe the main activity of your current business ( not more than 25 words):	*
Telephone Contact
Best day of week to contact you:	*
Best time of day to contact you:	*
Preferred Phone number:	*
Location Preference
Do you operate one or multi unit outlets?	One Outlet Multi Unit Outlets *
Describe the location of your main outlet (not more than ten words):	*
Would you like to receive more information from us?:	Yes No