become a customer — Jiva Organics

Customer Form

Simply fill out the form below and we will get in touch with you in 3 business days.

1. Contact information

Type of organization

Primary contact name

Legal name of business or organization

Number of store locations

Contact phone

(###)

###

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Fax

(###)

###

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Email address

Website

http://

2. Store address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Categories of interest

Tell us which of these interest you. This helps us to serve you better.

Grocery packaged items

Bulk

Household laundry and cleaning

essential oils

Natural personal care products

Natural supplements

Other

Additional comments or questions