APPLICATION FORM

Please note, this is not a contract or fixed term agreement. You can cancel your supply at any time. Stockists are chosen on a first-come-first-served basis.
* = mandatory field

Pharmacy manager*

Manager's name needed.

Pharmacy name*:

Pharmacy name needed.

Address*:

Address needed.

Postcode*

Postcode needed.

Tel*

Telephone number needed.

Fax:

E-mail*:

Email address needed.

How long have you been in business?

On average, how many customers visit your pharmacy each week?

How many staff do you employ?

Do you stock any other magazines?
Yes
No

If yes, please state:

What is your most popular natural product range?

Select one: Vitamins & Supplements Bodycare Herbal Other