Please use this request form for applying for a Distributor/Wholesaler position with AIE Pharmaceuticals, you may fill in the required information, print, and then fax the completed Application Form to us.  Upon receipt your request, the form will be processed immediately, and an agreement along with a complete package will be mailed to you immediately.

 APPLICATION FORM

   Applicant Information:
(You may type your information below)

 Applicant Name (Last, First)            

 Mailing Address                          

 City/Region                              

 State/Country                            

 Zip Code                                 

 Home Phone #                             

 FAX #                                    

 Cell Phone #                            

 Applicant Date of Birth                 

 Business Name (if any)                   

 Business Address                         

 City/Region                              

 State/Country                            

 Zip Code                                 

 Business Fed. ID#                        

 Business Phone #                         

 FAX #                                    

 Email                                   

                             

 Customer Comments:

                    

                         

                          

                         

                         
       

AIE Pharmaceuticals, Inc.
1845 S. Vineyard Ave., Ste 5
Ontario, California 91761
USA

Fax: 909-947 9813