TLC-Online Application Form

TLC Retail Application

To apply and register to become a TLC-Retailer, please fully complete and submit the following application form (do not leave out any answers as they are most important for considering your application and, if approved, your TLC-Retailer Registration).

To view the Q&A's and Explanations of the Terms and Conditions for TLC-Retailers please click here >>>

Title

First Name:

Last Name:

Date of Birth:

Gender:

Male Female

Marital Status:

ID/PASSPORT Number:

Citizenship/Nationality:

Street Address:

Address line 2:

Suburb:

City:

Province/State/County:

Country:

Postal Address:

Postal Code:

Business Address:

Street address:

Suburb:

Town:

Province/State/County:

Country:

Presently residing in:

City:

Province/State/County:

Country:

Mobile/Cell Number:

Country code:

Number: *

Home Telephone:

Country & area code:

Number:

Work Telephone:

Country & area code:

Number:

Best time and number to contact you telephonically:

E-Mail Address:

* I have read the Terms and Conditions for TLC-Retailers and
agree to full compliance as specified. View Terms and Conditions

Facebook Profile and Details/Address (if applicable):

Proposed TLC-Retailer area you wish to operate in (e.g. City and Country):

1st Choice:

2nd Choice:

3rd Choice:

*Where did you hear about TLC?

Have you done a TLC-Program?

Yes No

Please provide details:

Do you need to do a TLC-Program (based on your image/health profile)?

Yes No *

Is your Wellbeing-profile Healthy (add any comments)?

Do you intend running the business full time?

Fulltime Part-time *

Do you have/own an existing business (including own business name and branding) that you would like to add TLC-Programs/Products/Services to?

Yes No *

If so, please provide details:

Have you ever managed your own business?

Yes No *

If so, please provide details:

Your Home Language?

Can you speak, read and write English?

Yes No *

Other languages you can speak, read and write:

What is your current occupation/business? Give details:

List your Key Professional and Other Qualifications? Give details: *

Briefly list any Wellbeing/Health/Medical Industry Experience you may have. Give details:

Motivation/General Comments: