Exotic Nutrition Company         HOME     CUSTOMER SERVICE 

   Fill-out form -  Print from your computer - Fax to our office      

  Wholesale Purchasing Application Form   Fax form to:  757-988-0321

  In order for you to receive our wholesale pricelist, and begin purchasing on a                               wholesale basis we need to have the following  information from your organization. 

Customer Information
Legal Name: Do you currently sell our products?   Yes / No

Billing Address: 
Street: 
                  Suite:
City: 
State:            Zip: -

Telephone:  ( ) -
Fax:  ( ) -
E-mail: 

Shipping Address: 
Street: 
                  Suite:
City: 
State:            Zip: -

Telephone:  ( ) -
Fax:  ( ) -
E-mail: 

Name of Company: 

Web Site Address: 

Nature of Business:  (check all that apply)

Breeder    Retailer    Web-Site Store    Wholesaler   Shelter
Type of Business:

Corporation    Partnership    Proprietorship
Date Established: /
Annual Sales Volume:  $
Number of Employees:  		Federal Tax I.D. Number: 

USDA License number:  

Name and Title of Principal Owners or Officers:

1.  Name:    Title: 
2.  Name:    Title: