Applicant's Social Security or Tax I.D # ______-______-________

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Applicant's First Name / Middle Initial / Last Name (Commissions are made payable to the name on this line)

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Company Name (Use this line only if commission checks are to be made payable to company name)

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Mailing / Shipping Address - Print one address only - use Street Address or P.O Box

City____________________Province________________
Postal Code:____________Canada_________________

Area Code (_________) Home Phone Number ____________________

Area Code (_________) Work Phone Number ____________________

Area Code (_________) Fax Number_____________________________

 Sponsor's Name: Nattaly Dumais  ID Number: 266-329-903
Sponsor Address: 6611, rue de Meursault CITY:  St-Emile Province: Quebec
Zip: G3E 1S2 Country:   Canada Phone:

To become a distributor, simply complete and mail this form along with a Money Order or Cashiers check for $35.95 plus $7.95 Shipping and Handling for a Total of $43.90 US to the address below. We strongly suggest that on initial orders you send it to Herbatrol, Inc., via overnight delivery or 2nd day Air to eliminate the delay associated with regular mail.

Herbatrol, Inc.
5849 Okeechobee Blvd, Suite 201,
West Palm Beach, FL 33417, USA