ACCOUNT PROSPECT FORM Date Entered  * Company Name:  * Corporate Name: Contact Name:  * Title:  * Mailing Address:  * City:  * State:  * Zip Code:  * Shipping Address (if different from above) Phone #:  * Fax #: Email Address:  * Website Address: How did you hear about us?  * Select all that apply-We are a: Distributor Wholesaler Retailer Co-op Manufacturer Health Care Professional Caterer Restaurant Mail Order Gift Basket Co. Importer/Exporter Broker Website Sales Buying Club Other Re-Sale ID # (A copy of your Certificate must be submitted by email or fax) Federal Tax ID # or Social Security#:  * List your classes of trade: Supermarkets Wholesale Restaurant Gourmet Natural Kosher Speciality States/Countries Served:  * What Products are you interested in carrying from Natural Import Company? Mitoku Quality Natural Masu Lundberg Maine Coast Dr. Chang Do not enter anything in this field: