Application All completed applications will receive FREE samples, company information and copy of licensing agreement.   Salutation:*   Please select one... Mr. Mrs. Ms. Dr. First Name:* Middle Name: Last Name:* Date Of Birth:* Address:*   City:* County/District:* State:* Please select one... Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Yukon Zip/Postal Code:* Country:* Please select one... United States of America Canada United Kingdom Australia France Germany The Netherlands Do you own, rent or lease a home?* Please select one... Own Home Rent Home Lease Home Married or single? * Please select one... Married Single Spouse name? *   Work Phone:(with area code) *   Home Phone: (with area code) * Email: Very important *   What's the best time to reach you? *   Please select one... Morning Afternoon Evenings Weekends   Estimated Startup Date: *   Please select one... Immediately 30 Days 60 Days 90 Days   Are there any other Countries, States, Provinces, Counties, and Districts you would consider commuting to (or moving to) for your new business? *   Yes No   Please enter the market you wish to control the distribution of Hit Me Shots.*   Choice #1 City: County/District: State/Provinces: Countries: Please select one...   Should your first choice above no longer be available, please enter your next choice.   Choice #2 City: County/District: State/Provinces: Countries: Please select one...   How much time will you devote to your business? *   Full-Time  Part-Time   If you have any partner (s), please provide their First and Last Names: *   Ex: John Doe, Jane Smith   What degrees have you earned? (To choose multiple items, hold the CTRL down as you make your selections.) *   None Middle School High School Associate's Bachelors Master's Doctorate Medical Law   Please provide your professional experience: (To choose multiple items, hold the CTRL down as you make your selections.) *   Accounting Art Auto Service Building Computer Education Food General Business Health Human Resource Management Publishing Real Estate Retail Sales Security Sports   Present Occupation: *     *Please give three reasons why Black Lion Energy should consider you becoming a Distributor.         What types of sources will you use for funds? * (To choose multiple items, hold the CTRL down as you make your selections.)    Self Partner Family Loan       What is your approximate net worth? * (Net Worth = Assets - Liabilities)   Please select one... $10,000 - $20,000 $20,000 - $40,000 $40,000 - $60,000 $60,000 - $100,000 $100,000 - $200,000 $200,000 - $500,000 $500,000 - $1 Million $1 Million - $2 Million More than $2 Million       Please explain in your own words Below why you feel you will make a good Distributor for Hit Me Shots*         3 Character References Required *     Name:   Phone:   Name:   Phone:   Name:   Phone:

Copyright 2010, All rights reserved web design by comp-wiz.com  home distributor login retail login promotional support policies contact us