1 5 1 5W . ' l 9 0 t h t , S t e .5 3 5 S CA 90248 Gardena, ( P h o n e : 3 1 0 )5 3 2 - 9 0 0 0 F A X :( 3 1 0 )5 3 2 - 9 0 1 0
EnagicUSA, Inc. Headquarter
Distributor Agreement & Product OrderForm
tttl D i s t r i b u t oD N u m b e r lr
-v cno9rc
@)
Applicantlnformation
ttl State Driver's License Number rrttttttrtrttll , N l , A p p l i c a nN a m e( F i r s tM i d d l e n i t i a lL a s t )o r C o m p a n y a m e t trrttttlltlrttl Address ttl City tttl P h o n eN u m b e r F a xN u m b e r tttl tll State tl Z i pC o d e
ltl
lllllEMalenFemale Exoiration Date
rllrrll
Application Date(MM/DD/YY) ttttrtl
Dateof Birth(MM/DD/YY)
rtltttl A Shipping ddress rtrrtttttrtrtrttltll City rttl E-MailAddress
tltl
tl
State
Zip Code
ltl
Sponsor Information
ttrltttlltllltltllllllllll
S o o n s oN a m e r
Registertheapplicantas[ ] A ProductOrder
Product UnitPrice $ lSingle Payment P ! Enagic ayment EOther Credit Card Information
I
L
I
I
6
I
|
|
|
l
I
I
I
tttl
P h o n eN u m b e r
D i s t r i b u t oD N u m b e r lr
Office Use:
Handling SalesTax Shipping l S h i p p i n gn s .IVISA
E.P.S. 3
'10 16
trVlSA lMC
IAMEX.
DDISC.
Sales
Ext.Warr. Other Deposit D.P.Total N M A S T E RC A R D I]AMEX
Monthly Pymnt C C F o u rD i g i t s CheckNumberlPick-Up nShip
S.Sup. Acct. Comm.-
trDISCOVER !OTHER
l"rl'rrlrrrlrrrl
Exoiration Date ttrrttttttltltltltlllll
L C a r d H o l d e r ' sN a m e ( F i r s t ,M i d d l e I n i t i a l , a s t )
6A Support ttttttl lr D i s t r i b u t oD N u m b e r
PrintName(6A)
(64) Signature
Date
9
documents which set that I haveread,understood, agreedto the Termsand Conditions forthin the following and certify l, the applicant, Planand the Products.I Compensation Agreement, SalesContract, the Policies and Procedures, the the comprise Contract: Distributor may resultin the termination denialof or I statement am of legalage in my stateof residence. agreethat any falseor misleading will and not by recruiting I that reward comefrom salesof the products registration an EnagicDistributor. understand the financial as people. l, the sponsor whichthe applicant shouldknowpriorto sign up. to all information haveexplained the applicant relevant
Applicant Signature
Date
Sponsor Signature
Date