Dear Samson Life Dealer Applicant,

Thank you for your interest in the Green Power Juice Extractors for your business.

Samson Life, Inc. is committed to the success of each of our authorized dealers. Through you, we provide your customers with quality products that will give years of dependable service and lasting value.

Whether you are purchasing from one of our Authorized Distributors or purchasing directly from us, we would like to consider you as one of our Authorized Dealers. As an Authorized Dealer we can provide you with services such as:

• Provide you with extra brochures, posters, videos, etc. of the Samson Juicers as needed.
• Provide you with the right to use our Registered Trademark pictures, logos, etc. These can be sent to you directly from our head office, or can be taken from our website.
• Refer potential customers to your location if they are in your area.
• Provide you with a weekly list of these customers that have been referred to you, along with their contact information. This will be either mailed, faxed, or e-mailed. You may choose below.

We look forward to providing the best possible service for you and your customers.

Regards,
Everyone at Samson Life

PLACE YOUR FIRST ORDER WITH US NOW and receive customer referrals as an authorized Samson dealer, as soon as your application is approved! Download an order form, using the links below, and fax or mail in your order today.

Order Forms:
Microsoft Word document (131kb)
.jpg graphics file (131kb)

*All fields are required*

Legal Company Name:
Street Address:
City:
State:
Zip:
Billing Address:	(if different from above)
Shipping Address:	(if different from above)
Business Phone:
Toll Free:
Business Fax:
Would you prefer the weekly referral list faxed? Yes No
Business Email:
Would you prefer the weekly referral list e-mailed? Yes No
Business Website:
Will the Samson be sold at this website? Yes No

Date Business Started:
Days & Hours of Operation:
Who will be the buying or contact person(s):
Name and contact info of the company owner:
If more than one name listed above are you operating as: Partner   Corporation   State where incorporated
Which of the following best describes your business: Wholesaler   Retail Store   Catalogue House   Chiropractor Doctor Office   Health Institute   Home Business*   Internet Dealer Other (explain): *We cannot refer potential customers to your location.
Are you currently purchasing products from other manufacturers / distributors? Yes No Please list distributor information below: Name: Name: How Long: How Long: Phone: Phone: Address Line 1: Address Line 1: Address Line 2: Address Line 2: (This information may be used for future reference when considering credit terms. Credit terms are reserved for clients making larger, regular orders.)
Are you currently purchasing the Green Power from other distributors? Yes No Please list distributor information below:

Name:		Name:
How Long:		How Long:
Phone:		Phone:
Address Line 1:		Address Line 1:
Address Line 2:		Address Line 2:

(This information may be used for future reference when considering credit terms.
Credit terms are reserved for clients making larger, regular orders.)