Salon/Spa Name *                   

 

Owner’s Name *                         In Business Since

 

Business Address *               

 

City/State/ZIP *                        

 

Telephone Number *                ()  (This is the telephone number 1-800-SALON SPA will ring to)

 

Fax Number                             ()  Mobile Phone Number  ()

 

Email Address                        

                                 (This is the e-mail address where you will receive important updates about SALON SPA)

 

Web Site Address                   www.

 

Primary Retail Line                      In any Product Loyalty programs?

 

Complete ONE payment method: Electronic Checking OR Credit Card

 

Electronic Checking Authorization for The Becca Group, LLC                  Credit Card Information    

 

I authorize my bank to make payment from the checking account number            Check one:                 Visa                 MasterCard                  

below and post it to my account.  I understand that I am in control of

my payment, and if I decide to make any changes or discontinue the                  

electronic checking service, I will inform The Becca Group, LLC in writing.         Card #                          

 

Name on the Account                       Expiration Date  

 

Bank Name                                       Name on Card    

                                                                                                               

Account No.                                     Billing Address  

 

Bank Routing No.                              Zip Code     

 

 

  I agree to the terms and conditions I hereby accept and agree to the terms and conditions of the Standard Shared Use Agreement attached to this Application.