Dr. Smoothie

NEW CUSTOMER FORM

Set-up a Business Account
If you would like to set-up a business account that allows you to purchase our products, simply fill out the form below and a representative will contact you with 2-3 business days to get you started.

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* Required Field

Company Name *

Contact Name *

Title

Primary Phone Number *

Type

Extension

Secondary Phone Number

Type

Extension

What is the best time of day to contact you?

Address 1 *

Address 2

City *

State/Province *

Zip/Postal Code *

Country *

Residential/Commercial *

Email *

How did you hear about us?

Please explain which advertisement:

Please explain which mailer:

Please explain which trade show:

Please explain:

Is your business currently open? *

Yes No

If so, how many locations do you have?

If not, when is your scheduled opening date?

Are you a part of a franchise? *

Yes No

What type of products do you currently carry?

Smoothies Coffee Products Other

Please explain

Which products are you interested in?

100% Crushed® Fruit Smoothie Puree Classic Fruit Puree Blend Fit Lyte Organic Smoothies Cafe Essentials Supplements Organic Frappe & Hot Beverages

Which best describes your business?

What type of distributor are you?

Please explain:

Are you buying smoothie/coffee products from any distributors? *

Yes No

If so, please list which distributor and products:

Are you currently buying Dr. Smoothie products? *

Yes No

From where?

Any additonal questions or comments?