Application Form

Complete this form to apply for Authorized Distributor and Authorized Practitioner Representative status or complete form to request information to Distribute or Represent Pure-Charge Energetic Spa, TriVortex Chargers or VitaShower Products.

All applicants for Practitioner Representatives and Sales Distributors must complete the following steps before final approval is granted: 1.) Submit Application Form below and, 2.) Submit Dealer Agreement for Distribution & Representation and, 3.) submit your payment of the one time $30.00 Application Fee.

Please check the boxes that apply and complete the following Application Form. Once submitted, your application will be confirmed via email with further information for entering the password protected REP area. Applications, first orders and Distributor inquiries may be accompanied by a personal consultation to ensure your needs are met. All personal information is held in strict confidence. You will NOT be added to a mailing list nor your information sold to others.

	Select the products that you wish to represent. Pure-Charge Spa REP Tri-Vortex Charger REP VitaShower/VitaBath REP
	Select the Status you are applying for. Sales Distributor Practitioner Representative Both
	Select your preferred method of contact. Personal Consultation-Contact by Phone Contact by Email
	What are your intentions? Sales Offer Treatment Services Both
	Where do you plan to conduct sales or services? Home Office Clinic or Independent Practice Store Front In- Home Demonstrations Expositions or Trade Shows
	What are your professional credentials, your area of expertise, your level of experience in Sales or as a Health Practitioner? Why do you wish to represent our products? Expand on your intentions...
	Please provide the following contact information. Required Fields First Name Last Name* Company City * State/Province* Country Phone with area code* Fax with area code E-mail* Website Referred by:

**Click ONE time on "Submit Form". If you reach the confirmation page, your application submission is complete. Return to form and continue browsing. Your application will be confirmed via email.**

Do you prefer to contact us before submitting this Application?

ENVIRO-HEALTH-TECH
2250 Highway 95, Suite #556-172
Bullhead City Arizona 86442

Office: 928-758-7689
Voicemail: 1-800-906-2624 EMAIL: envirohealthtech@yahoo.com

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