New Distributor Account Form Distributor Registration Name Username* First Name Last Name Nickname Contact Info E-mail* Website About Yourself Biographical Info Password* Repeat Password* Distributor Owner or Manager: Distributor Sales Reps (separate by comma): Additional Sales Reps listed if needed: Distributor Billing Address: City: State: Zip Code: Distributor Shipping Address if Different from Billing City: State: Zip Code: Commission Payment Information: Name of Business for Payment: Federal Tax ID (please send signed W9 for business): Bank Name: Bank Routing Number: Bank Checking Account Number: