OUR VITAL EARTH

Confidential Application

Phone: 1-800-237-4780

6919 Plymouth-Sorrento Rd.
Apopka, FL 32712

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Note: This form is to be used only by those interested in our Associate Grower Program. Click here for other correspondance.
Full Name*
Telephone Number (area code first)*	Home Work Cell
Fax Number (area code first)
Street Address
Address Line 2
City
State	Choose a State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam 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 North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip / Postal Code
Country	Choose a Country United States of America Canada United Kingdom --------------------- Not Listed___________________________
e-mail Address*
Best Time to call
How did you find us?
How long have you been searching for a business?
What are your income expectations?
Are you prepared to invest in establishing your own business, which may present challenge and risk? Yes No
When will you be ready to start? immediately 3-6 Months 6 mon - Year Over 1 year
Do you have a partner that would be involved with you in the program? If yes, who?    Spouse Business Associate Family Member Are they aware of your interest? Yes No
How much liquid capital are you willing to risk? Under $5000 $5,000-$15,000 $15,000-$25,000 over $50,000
Will you have to borrow the funds?  Yes No
What experience do you have which you believe would enable you to succeed as an associate worm grower?
Questions, Comments, Suggestions
Note: This form is not a contract nor a promissory note and does not guarantee acceptance into our Associate Grower Program.

 * Required field