Your name: Company Name:
Street Address: City: State: Zip:
Phone: FAX:
E-Mail address:
Website (if you have one):
Your primary product and/or service:

Are you familiar with our products and/or services? Yes     No

Are you familiar with our Learning Style Profile? Yes    No

Comments or other information you want us to know about you:

Thank you for applying to A Self-Portraitª Online Sales Associate Program!

   Please online or print out and  

   mail to: REP, 1590 E. Main St., Ventura, CA 93001

   or fax to: 805-648-1769