Gaia's World New Retailer Application

SECTION 1, Company info:
Legal Business Name *
Legal Structure *

Corporation LLC Partnership Sole Proprietor
Year established
Store Name *

Store Name

Street Address

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Fax Number

Area Code Phone Number
Resale Tax Number *
Website URL
Federal Tax ID
Contact person *
e-mail Address *
Types of products sold
suggestions/comments
SECTION 2, Owners/Officers of Company:
(1) First owner/officer

First Name Last Name
Title/position
Phone Number

Area Code Phone Number
Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
(2) Second owner/officer

First Name Last Name
Title/position
Phone Number

Area Code Phone Number
Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
SECTION 3, Current Business References:
List only open accounts from whom you currently buy products.
1. First Business Name
Phone Number

Area Code Phone Number
Products
2. Second Business Name
Phone Number

Area Code Phone Number
Products
3. Third Business Name
Phone Number

Area Code Phone Number
Products
SECTION 4, Credit Card Authorization:
For your convenience, we accept credit card payments by phone. However, we are no longer allowed to keep your credit card info on file. To expedite your order, please include your credit card number, expiration date, CID code, and billing zip code on all faxed or emailed orders. Be prepared to give us your credit card information each time you order by phone
Credit Card Bill-to Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Name on card
Phone Number

Area Code Phone Number
Check to authorize *

I authorize you to bill my card when I place an order or make a payment.
Signature

Clear
You must email us a copy of your Business License and State Sales Tax certificate after submitting this form. Email to info@GaiasWorld.com.

After we receive your license and certificate we will email your login information.

Thank you, Gaias World Ceremonial Herbs®.

Hit the 'Submit Info" button below to send this form.
Should be Empty:

SECTION 1, Company info:

SECTION 2, Owners/Officers of Company:

SECTION 3, Current Business References:

SECTION 4, Credit Card Authorization: