Request Date:

Contact Name:

Company/Organization Name:   

Address:

City:       

State:               Zip Code:

Phone Number:

Fax Number:    

E-Mail Address:

Under which category are you requesting distribution approval?

 Category One: Not for Resale       Category Two: Not-for-Profit Fundraising

 Category Three: Commercial Resale

Please briefly describe how your intended use of Norfolk Pure aligns with Norfolk’s intended uses and promotional/educational goals:

Please provide information about your event/venue:

Number of Cases Requested: (24 bottles per case)

Name of Event/Venue:

Briefly Describe Your  Use/Event:

Date of Your Event:

Delivery /Pick-Up Date Requested:

Location of Event: