*Denotes Required Field

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?

Store Mobile

E-mail (primary) *

E-mail (secondary, if any)

How do you sell products?

Brick-and-mortar store
Online / website / e-commerce
Both brick-and-mortar and online stores

Type of store or business. Check all that apply or one that best describes:

Bariatric
Boutique / gift / flower shop
Chiropractic
Diabetic foods or supplies
Dietician / nutritionist
Distributor (warehouse / wholesaler)
Fitness club / gym / personal trainer
General store
Grocery / supermarket / market
Health food / nutrition
Home office / ran from residence
Hospital or medical facility for meal prep / food service
Hospital or medical facility with weight loss or special program for health
Ice cream / yogurt
Meal prep / food service
Medical
Med-spa
Pharmacy
Sugar-free / low carb / gluten free
Restaurant
Sports nutrition / vitamins / supplements
Weight 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?