www.luminanti.com WHOLESALE Application Form Revised 2-25-08 USA residents include copy of RETAIL SALES TAX LICENSE. Non-USA include copy of PROFESSIONAL CERTIFICATE Print out, complete form & FAX 919-563-1522 or send to address at the bottom of form *required information *COMPANY INFORMATION Name* _________________________________________ Business Name* _________________________________________ Is Company Address Residential?* Yes _____ No ______ Address Line 1* _________________________________________ Address Line 2 City* _________________________________________ State* _________________________________________ 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 those fields BELOW which are different. Name* _________________________________________ Business Name* _________________________________________ Address Line 1* _________________________________________ Address Line 2 _________________________________________ City* _________________________________________ State* _________________________________________ Province _________________________________________ Zip Code* _________________________________________ Country* _________________________________________ Daytime Phone* _________________________________________ Evening _________________________________________ Phone _________________________________________ Fax _________________________________________ Email Address* _________________________________________ *PAYMENT INFORMATION Credit Card* or Debit Card* Visa* Mastercard* Discover* Card Number* _________________________________________ Expiration Date* _________________________________________ 3-digit CVV2 Security Number* ___________ Name on Card* _________________________________________ Address Line 1* _________________________________________ Address Line 2 _________________________________________ City* _________________________________________ State* _________________________________________ Province _________________________________________ Zip Code* _________________________________________ Country* _________________________________________ *CHECK PRODUCTS below that you wish to purchase at Wholesale Colourworks (available anywhere) Tuning Forks (available anywhere) Wind Chimes (available anywhere) Golden 'C' Structured Water (available in USA ONLY) *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.
*WEBSITE NAME: www._________________________________________________________
*FREQUENCY OF PURCHASES Please document how often you plan to purchase each wholesale product line.
*SIGNATURE Signature____________________________________________ Date_____________________