| *First Name |
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| *Last Name |
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| Title |
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| *Company |
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| *Address 1 |
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| Address 2 |
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| *City |
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| *State / Province |
(for U.S./Canada)
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| Province |
(for other international countries) |
| *Zip / Postal code |
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| *E-mail |
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*What is your primary business type (select one)?
A. Natural/Health/Organic Food Store
B. Supermarket
C. Drug Store/Pharmacy
D. Natural/Nutritional Product Broker
E. Wholesaler/Distributor
F. Manufacturer/Supplier
G. Professional Health Care
H. VItamin/Nutritional Supplement Store
Z. Other
If other, please specify
*What is your primary job title (select one)?
A. Owner, President, Chairperson, CEO, Partner
B. VP, COO, CFO, GM
C. Division/Regional/Store Director or Manager
E. Health Care Practitioner
F. Marketing/Sales Director or Manager
G. Buyer
H. Researcher/Product Developer
J. Nutritionist/Dietician/Wellness or Health Consultant
K. Retail Sales Associate
L. Package Designer
Z. Other
If other, please specify
What type(s) of products are sold at your facility (select all that apply)?
A. Vitamins
B. Supplements
C. Minerals
D. Herbs/Homeopathics
E. Sports Nutritional Products
F. Functional/Fortified Foods
G. Functional/Fortified Beverages
H. Vitamins/Supplements for Pets
Z. None Of the Above
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*In what month were you born?
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