04-25-11

To submit an application, please follow these 4 easy steps or call us at 919-563-1600 or complete a FAX FORM and fax it to 919-563-1522 Click this link wholesale@luminanti.com to open a blank email page Copy and paste the information listed BELOW this yellow box into the blank email created in step 1 Edit the email to answer each item in the list. Then "Send" the email We will process your application as soon as we receive it. Thank you.

Copy into email and email to wholesale@luminanti.com
*required information

*COMPANY INFORMATION
Name*
Business Name*
Is Company Address Residential?* Yes _____ No ______
Address Line 1*
Address Line 2
City*
State/Province*
Province
Zip Code*
Country*
Daytime Phone**
Evening Phone
Fax
Email Address*

*SHIPPING INFORMATION
Is Shipping Address Residential?* Yes _____ No ______
Check here if the SHIPPING Information is the same as the COMPANY information
above. Otherwise, complete the fields BELOW.
Name*
Business Name*
Address Line 1*
Address Line 2
City*
State/Province*
Province
Zip Code*
Country*
Daytime Phone*
Evening
Phone
Fax
Email Address*

*PAYMENT & BILLING INFORMATION
Visa* Mastercard* American Express* Discover*
Credit Card* or Debit/Check Card*
Card Number*
Expiration Date*
3-digit CVV2 Security Number*
Name on Card *
Address Line 1*
Address Line 2
City*
State/Province*
Province
Zip Code*
Country*

*CHECK PRODUCTS below that you wish to purchase at Wholesale

Tuning Forks (available anywhere)
Golden 'C' Structured Water (available worldwide)
Wind Chimes (available anywhere) CURRENTLY UNAVAILABLE

*YOUR RETAIL SITUATION
Please explain in detail who you will be retailing each product line to and how you will be selling each product line.

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*WEBSITE NAME www.__________________________________________________________

*FREQUENCY OF PURCHASES
Please document how often you plan to purchase each wholesale product line.

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*SIGNATURE
Signature____________________________________________ Date_____________________