Contact Person*

Contact Person’s Title

Company Name*

Address*

Address (continued)

City*

State*

Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code*

Phone Number*

Fax Number

E-Mail Address*

Website

Type of Business* (e.g. Plastic Surgeon’s Office, Spa, Salon, etc.)

Number of Years in Business*

Number of Employees*

Do you employ licensed aestheticians?* Yes No  If yes, how many?

What services do you provide?*

Are you interested in our retail line, our professional line, or both?*
Retail Line Professional Line Both Lines

Are you interested in training?* Yes No
If yes, how many employees would attend?

Do you currently sell another skin care product line?* Yes No
If yes, which one?
If yes, and if selected by Elina, do you intend to phase out your current line or continue to sell both? Phase out other brand Sell both

Why do you want to carry Elina’s Elite line?*

Please list at least three credit references:

Reference 1*

Reference 2*

Reference 3*

Reference 4

Reference 5

Additional Information