RETAILER APPLICATION FORM
Thanks for your interest in Shelf Life! Help us learn more about your business by completing this form.

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Name of Business *
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Number of Locations *
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Name of Owner/Primary Contact *
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Phone Number
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Superintending Pharmacist Name
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Superintending Pharmacist License No.
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Premises License No.
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Address & Landmarks
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City
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Country
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Years in Operations
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Reason for Interest (select all that apply)
Primary Source of Traffic (select all that apply)
Average Monthly Sales (at one location)
How did you hear about Shelf Life?
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