Essentially Yours Industries Corp.
#201, 8322-130th Street, Surrey, British Columbia, Canada V3W 8J9
Telephone 604-596-9766      Facsimile: 604-596-9455
Product Order Form - [USA]
Associate Information:
First M.I. Last
SSN, Federal I.D. or Company I.D.#
Shipping Information: information below is for the person RECEIVING the shipment...please include phone number(s)...no P.O. Boxes...must be a physical street address.
First M.I. Last
Shipping Address
City State Zip Code
Home Phone# Work Phone# Fax#
Product Order Please credit this order to Retail Business Center # Is this a requalification order? yes no
Item #
Qty
Product
Taxable
Unit Retail
Associate
Unit Cost
Taxable
Retail Subtotal
Associate
Cost Subtotal
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*A PARTICIPANT IN THIS MARKETING PLAN HAS A RIGHT TO CANCEL AT ANY TIME, REGARDLESS OF REASON. CANCELLATIONS MUST BE SUBMITTED IN WRITING TO THE COMPANY AT ITS PRINCIPLE PLACE OF BUSINESS AND ALL UNOPENED MATERIALS RETURNED FOR FULL REFUND LESS 10% SHIPING AND HANDLING CHARGES.*
By signing below, I have acknowledged that I am an Independent Business Associate (IBA) for Essentially Yours Industries Corp. I acknowledge receipt of the IBA Agreement. I have closely read, understand, and willingly agree to be bound by and am in full compliance with these policies and procedures. I have enclosed my money order or cashier's check for the total amount due. I understand that once package is opened, there is no refund or return. I certify that I have sold to retail customers or consumed at least 70% of all Essentially Yours Products that I have purchased. Sales volume will not be credited to the Associate for my product purchases if not ordered and shipped directly from Essentially Yours.
The undersigned authorizes product payments to me, charged to:
Visa MasterCard (check one) Pre-Authorized
Acct# Exp. Date
Date Signature
Associate Cost Total:*
State & Local Sales Tax:_____% x =
Standard Ground: Subtotal (A) x 5%
2nd Day Air: Subtotal (A) x 8%
Next Day Air: Subtotal (A) x 15% =
Shipping
Handling:
Total Due(A+B+C+D): Visa
MasterCard
Money Order
Cashier's Check

ALL FUNDS PAID IN U.S. DOLLARS      *Minimum Order: $50.00 @ Associate Cost

Date ___________________________

Signature ___________________________