HIKARI RETAILER DATABASE REGISTRATION FORM
* (required)
Store Name*
E-Mail Address:*
STORE INFO
Address Line 1:*
Address Line 2:
City:*
State/Province/Region:*
Postal/Zip Code:*
Country:*
--- Select one ---
United States
Canada
Puerto Rico
Owner:*
Manager:*
Assistant Manager:
Phone#:*
Fax#:
Website URL:
SUPPLIERS
Primary Supplier:*
Secondary Supplier:
Other Suppliers:
PRODUCTS CARRIED
What type of products do you sell? (check all that apply):
Freshwater Fish Products Saltwater Fish Products Reptile Products Bird Products
What type of live animals do you sell? (check all that apply):
Freshwater Fish Saltwater Fish Reptiles Birds
Store Area (sq.ft.):*
--- Select one ---
0 to 499 sq.ft.
500 to 999 sq.ft.
1000 to 1499 sq.ft.
1500 to 1999 sq.ft.
2000 to 2999 sq.ft.
3000 to 3999 sq.ft.
4000 to 4999 sq.ft.
5000 to 5999 sq.ft.
6000 sq.ft. or more
Live Aquatics Area (sq.ft.):*
--- Select one ---
0 to 499 sq.ft.
500 to 999 sq.ft.
1000 to 1499 sq.ft.
1500 to 1999 sq.ft.
2000 to 2999 sq.ft.
3000 to 3999 sq.ft.
4000 to 4999 sq.ft.
5000 to 5999 sq.ft.
6000 sq.ft. or more
Total number of Hikari® items currently in stock:*
HIKARI FISH DIETS
Which ®Hikari Goldfish Diets do you currently stock? (check all that apply):
®Hikari Goldfish Gold® ®Hikari Goldfish Staple™ ®Hikari Lionhead ®Hikari Oranda Gold® ®Hikari Wheat-Germ Saki-Hikari® Fancy Goldfish
Which ®Hikari Koi & Pond Diets do you currently stock? (check all that apply):
First Bites® ®Hikari Economy™ ®Hikari Excel™ ®Hikari Gold™ ®Hikari Hi-Growth™ ®Hikari Sinking Wheat-Germ ®Hikari Spirulina ®Hikari Staple™ ®Hikari Wheat-Germ Saki-Hikari® Color Enhancing Diet Saki-Hikari® Growth Diet Saki-Hikari® Multi-Season Diet Hikari Sturgeon Hikari Silkworm Selects
Which ®HIKARI CICHLID Diets do you currently stock? (check all that apply):
Cichlid Bio-Gold+® Cichlid Excel® Cichlid Gold® Cichlid Staple™ Sinking Cichlid Gold® Sinking Cichlid Excel®
Which ®HIKARI TROPICAL Diets do you currently stock? (check all that apply):
Algae Wafers™ Betta Bio-Gold® Crab Cuisine® Discus Bio-Gold® Fancy Guppy® First Bites® Food Sticks™ Jumbo CarniSticks Massivore Delite® Micro Pellets® Micro Wafers® Shrimp Cuisine™ Mini Algae Wafers™ Sinking Carnivore Pellets® Sinking Wafers®
Which ®HIKARI MARINE Diets do you currently stock? (check all that apply):
Marine-A-® Marine-S-®
REPTILE DIETS
Which ®HIKARI REPTILE Diets do you currently stock? (check all that apply):
Crab Cuisine® Turtle Sticks™
FROZEN/FREEZE-DRIED FOODS
Which ®Hikari BIO-PURE® Frozen Foods do you currently stock? (check all that apply):
BIO-PURE® Blood Worms BIO-PURE® Brine Shrimp BIO-PURE® Brine Shrimp (Baby) BIO-PURE® Spirulina Brine Shrimp BIO-PURE® Clam On A Half Shell BIO-PURE® Daphnia BIO-PURE® Discus BIO-PURE® Krill BIO-PURE® Mega-Marine™ BIO-PURE® Mega-Marine™ Algae BIO-PURE® Mega-Marine™ Angel BIO-PURE® Mega-Tropical™ BIO-PURE® Mysis Shrimp BIO-PURE® Mysis Shrimp (Jumbo) BIO-PURE® Ocean Plankton BIO-PURE® Rotifers BIO-PURE® Silversides BIO-PURE® Squid BIO-PURE® Tubifex Worms BIO-PURE® UVX™ Blood Worms BIO-PURE® UVX™ Brine Shrimp
Which ®Hikari BIO-PURE® FD Freze Dried Foods do you currently stock? (check all that apply):
BIO-PURE® FD Blood Worms BIO-PURE® FD Brine Shrimp BIO-PURE® FD Daphnia BIO-PURE® FD Krill BIO-PURE® FD Ocean Plankton BIO-PURE® FD Spirulina Brine Shrimp BIO-PURE® FD Tubifex Worms
WATER TREATMENT
Which Aquarium Solutions® or Pond Solutions® Brand Water Conditioners do you currently stock? (check all that apply):
Betta Ultimate® ClorAm-X® Stress-X® Ultimate®
Which Water Treatments or Health Aid do you currently stock? (check all that apply):
Betta Revive™ Bio-Bandage® BiFuran+™ CyroPro™ GermGone™ Ich-X® Ich-X® SW Metro+™ PraziPro™
WATER FILTRATION SYSTEMS
Which Water Filter/Cleaners do you currently stock? (check all that apply):
Takara Water Cleaner TW-012 Takara Water Cleaner TW-022 Takara Water Cleaner TW-061 Takara Water Cleaner TW-081 Takara Water Cleaner TW-104
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