Applicant's Social Security or Tax I.D # ( you can use your phone number ) ______-______-________
_________________________________________________________________________________
Applicant's First Name / Middle Initial / Last Name (Commissions are
made payable to the name on this line)
_________________________________________________________________________________
Company Name (Use this line only if commission checks are to be made
payable to company name)
_________________________________________________________________________________
Mailing / Shipping Address - Print one address only - use Street Address
or P.O Box
City____________________State/Province________________
Zip/Postal Code:____________Country______________________________
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's 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 $8.95 Shipping and Handling for a Total of $44.90 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
