Name: *
Farm/Company:
Address: *
Address2:
City: *
State/Province: *
Zip: *
Country: (other than USA)
Phone:
Fax:
E-mail: *

Type of Activity (Check Primary Activity)
		Home/Personal Use
		Farmer
		Personal Care Formulator
		Food/Nutraceutical Manufacturer
		Feed Formulator
		Feed/Fertilizer Dealer or Distributor
		Fertilizer Formulator
		Ingredients Broker
		Other
I produce certified organic products.		Yes        No
Do you or have you previously used kelp?		Yes        No
For what uses are you considering Thorvin? (Check all that apply)
Agriculture
		Feed Supplement
		Fertilizer
		Other
	# of Acres
Types of Livestock
		Cattle
		Horses
		Goats
		Sheep
		Other
	# of Animals
Personal Care (Check all that apply)
		Skin Care
		Weight Loss
		Cosmetic Formulations
		Other
Home Use
		Fertilizer
		Pet Care
		- Dogs
		- Cats
		Other
Food and Nutraceuticals
		Food
		Vitamin/Mineral Supplement
		Other