Renewal® HGH

Distributor Form

Welcome! We appreciate your interest in our line of Renewal® HGH products. We also thank you for taking the time to fill out the following form. When you have finished please click the Submit Form button at the bottom.

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The first four (4) fields are required.     First Name     Last Name     E-mail Address     Country --------------------------------------------->>> USA Other (Unlisted) Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo, Republic of Cook Islands Costa Rica Cote d'Ivoire Croatia Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard & McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao Republic Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Ireland Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Russian Federation Rwanda Samoa San Marino Sao Tome and Principe Saudi Arabia Scotland Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea Spain Sri Lanka St. Barthelemy St. Christopher St. Croix St. Eustatius St. John St. Helena St. Kitts & Nevis St. Lucia St. Maarten St. Martin St. Pierre and Miquelon St. Thomas St. Vincent Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wales Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe >     Position / Title     Company Name     Address Line 1     Address Line 2     City     State/Province     Zip/Postal Code     Telephone Ext.     Cell/Mobile Phone     Fax Number

We ask that you answer all of the following questions.   How did you hear about Always Young® and/or Renewal®?     Please Select Search Engine From a Renewal Customer Catalog Classified Ad ContestGuide.com Family / Friend Magazine Ad Newspaper Ad Other Website Press Release Radio Retail Store Television Trade Show Other (unlisted)>     If “Other” please explain briefly:                   Why do you want to distribute Always Young® products?                   Which of our products are you interested in?       Renewal® HGH Advanced   Renewal® HGH Workout For Men   Renewal® HGH Power For Women   Renewal® IGF-1   Renewal® HGH Original               In what countries and/or regions (South America, Asia, etc.) are you looking to distribute?       USA   Other     » Please list Other:                   Do you currently distribute health products?       Yes   No   If yes:     How many years have you been distributing?         What types of health products do you distribute?         How extensive is your current distribution?                   What are the estimated volumes you anticipate distributing?   Number of bottles per month during these time periods:     Year One:       First 3 months (average per month)       Second 3 months (average per month)       Third 3 months (average per month)       Fourth 3 months (average per month)       Year Two:       First 6 months (average per month)       Second 6 months (average per month)       Year Three:       Entire Year (average per month)               How do you intend to market Renewal®?       Wholesale to Retail Outlets     » Types of Retail Outlets:       Wholesale to Private Practitioners     » Types of Private Practitioners:       Television Commercial / Infomercial   Radio Commercial / Infomercial   Your Internet Site   Other Internet Sites   Catalogs   Direct Mail   Network Marketing (MLM)   Other     » Please list Other:

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We thank you again for your interest in our products, and for taking the time to fill out this form. Someone from Always Young will contact you before the end of the second business day. The Always Young Staff             Privacy Guarantee Always Young® is committed to safeguarding the privacy of any information you forward to us. We will not sell, lend, share or distribute this data.