Store or Business Name*

Address*

City*

State*

Zip code*

Website (provide website, if any, even if product will not be sold online)

Contact name*

Position / title

Owner's name (If different than contact name)

Store phone*

Mobile phone (optional)

Which phone do you prefer to be called on?
—Please choose an option—StoreMobile

E-mail (primary)*

E-mail (secondary, if any)

How do you sell products?
Brick-and-mortar storeOnline / website / e-commerceBoth brick-and-mortar and online stores

Type of store or business. Check all that apply or one that best describes:
BariatricBoutique / gift / flower shopChiropracticDiabetic foods or suppliesDietician / nutritionistDistributor (warehouse / wholesaler)Fitness club / gym / personal trainerGeneral storeGrocery / supermarket / marketHealth food / nutritionHome office / ran from residenceHospital or medical facility for meal prep / food serviceHospital or medical facility with weight loss or special program for healthIce cream / yogurtMeal prep / food serviceMedicalMed-spaPharmacySugar-free / low carb / gluten freeRestaurantSports nutrition / vitamins / supplementsWeight loss

If any specific diet or protocol is used, please specify

Other (please explain)

If store is not currently open for business, what is approximate date to open?

If business is run from residence or home office, tell us a little about your business

How did you hear about Walden Farms?

Additional comments. Is there anything else you want us to know?

Δ