US ACCOUNT ACTIVATION
Before filling out the form, please read the following: By submitting this form, you claim that: You are a licensed skin care professional (your license number will be required before you can be approved) and You live in the United States or Bermuda or the Caribbean and As a new customer, you agree to buy at least one treatment or purchase $1000 worth of products for your first order. I agree to the above terms and conditions Please complete the following. Most of the fields are required. Company First Name Last Name Title CEO COO CTO Dermatologist Director Distributor Doctor Esthetician Esthetician/Nurse Marketing_Manager Medical_Esthetician President Salon_and_Spa_Manager Salon_and_Spa_Owner Salon_Manager Salon_Owner Spa_Manager Spa_Owner E-mail Address City State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington D.C. Washington West Virginia Wisconsin Wyoming Zip Phone Name of Owner/Manager Owner/Manager Phone Mgr E-mail License number and State of License How did you hear about our line ? What are you looking to do ? Check all that apply Add a line Changing lines Just opening, looking for line Create or update website Create or update brochure Create or enhance logo Develop or enhance retail sales Acquire equipment for aesthetic treatments Other, please indicate below Please complete for other Is retailing important to you? Yes No What product lines do you currently carry ? Please select Type of Business Full Service Salon Spa or Day Spa Individual Esthetician Dermatologist Plastic/Cosmetic Surgery # of Treatment Rooms 1 2 3 4 5 6 7 8 9 10+ # of Treatments/Week 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91+ # of Estheticians 1 2 3 4 5 6 7 8 9 10+ # of Massage Therapists 0 1 2 3 4 5 6 7 8 9 10+ What is your immediate need ? What is the timeline for your decision ? Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 When is a good time to contact you or the owner ? Day of week M-F Monday Tuesday Wednesday Thursday Friday Time of day Mornings Afternoons Evenings Overtype any additional relevant info here ! MOST FIELDS ARE REQUIRED!
