RESELLER APPLICATION FORM
Thank you for your interest in becoming a Reseller of Cellgevity with MaxLife Products. Please complete this form and one of our team will be in touch.
Your Full Name
Company Name
Your Phone Number
Your Email Address
Your Address, including City, State, Country
Were you previously a registered Associate with Max Nigeria?
Yes
No
Not Sure
If you were previously a Max Associate please provide your Max ID
Describe your business
Pharmacy Retail
Pharmacy Wholesale
Other Retail
Affiliate Marketing
Other (with description below)
Other (with description) Please describe your business below
If you have Retail outlets, how many locations do you have and where are they located?
How many units of Cellgevity do you anticipate selling monthly? 1 unit of Cellgevity is a one month supply.
How did you hear about Cellgevity and MaxLife / maxlifestore.com ?
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