ORDERING INFORMATION

* First Name

* Last Name

* Address

* City

* State

* Postal Code

* Phone

* Email

* Web Address

(do not include "http://" or "www")

* Tax ID/Resell Certificate

Type of product for your event

Private label
SmartShield label

Estimated quantity

250-1,000
1,000-5,000
over 5,000

Projected date of event

Type of event

Tradeshow
Fundraising
Promotional
Other

Have you purchased our
products before?

Yes
No

What products are you interested in?

Lotions
Gels
Face/Lip Sticks
Spray with Insect Repellent
Economy Sizes
Private Label

How did you hear about
SmartShield?

Search engine
Another web site
Friend or colleague
Print ad
Other

* Required information