Healthcare Professionals/Distributors Application Form

If you are a healthcare practitioner or health and wellness retailer and would like to distribute Immuno-Viva® products, please complete and submit the following form.

*Contact Name

Business/Practice Name

Address

City

State

Zip/Postal Code

Country

*Telephone

Fax

*Email

Website

*Please explain your type of business and the clients you serve.

Please describe your distribution area (city, state).

Which Immuno-Viva® Products do you plan on carrying?

Immuno-Viva Core
Immuno-Viva Ease
Immuno-Viva Boost
Immuno-Viva Smart

Immuno-Viva Recovery
Immuno-Viva Probiotic+
Free Radical Test

Projected Annual Purchase (in $)

Do you have retail location?

Yes No

Do you have a warehouse or storage facility?

Yes No

Are you willing to provide feedback regarding success stories related to your clients' using the Immuno-Viva products?

Yes No

NOTE: Minimum initial order to become a distributor is $500. Subsequent orders do not have a minimum. There is no auto reorder program available for distributors at this time.