Essentially Yours Industries Corp. #201, 8322-130th Street, Surrey, British Columbia, Canada V3W 8J9 Telephone 604-596-9766      Facsimile: 604-596-9455

Independent Business Associate Application and Agreement - [USA]

Associate Information:
SSN, Federal I.D. or Company I.D.#
First M.I. Last
Shipping Address (Street or P.O. Box)

City State Zip Code
Home Phone #
Work Phone # Fax Phone #

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Sponsoring Associate Information
First M.I. Last
Sponsoring Associate Federal Tax # or Company ID #       Apply to Business Center #
                                                                       

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Placement Information
Place under:
First M.I. Last
SS# or ID# or Co. ID#       Retail Business Center #       Left       Right
                                        

Type of Business:	Associate only     Single     Trio
I hereby apply to become an Independent Business Associate for Essentially Yours Industries Corp. I HAVE READ AND UNDERSTAND AND AGREE TO ABIDE BY THE PROVISIONS WHICH ARE PRINTED ON THE BACK OF THIS AGREEMENT. IBA WILL NOT MAKE ANY CLAIMS, WHAT SO EVER, OF THERAPEUTIC, MEDICAL OR CURATIVE VALUE OF ANY KIND RELATING TO ANY OF EYI PRODUCTS. INITIAL HERE___________. I UNDERSTAND THAT I HAVE THE RIGHT TO CANCEL THIS AGREEMENT AT ANY TIME, REGARDLESS OF REASON. Cancellations must be received in writing to the Company's mailing address: #201, 8322-130th Street, Surrey, British Columbia, Canada V3W 8J9	Administration Fee:      $25.00 Please submit payment at time of application ALL FUNDS PAID IN U.S. DOLLARS
Independent Associate Signature______________________________ Date___________ Company Use Only Accepted By___________________________ Date___________