913 High Rd.
Manitou Springs, CO. 80829 Telephone: 719.685.1488 Facsimile
719-685.5435
Associate Application and Agreement
Presented
By
Preferred Customer
Associate
Enrollment
Status Change
Applicant Information
Social Security or
Federal Tax ID Number (required for Associates):
Date of
Application:
Last Name: First Name: Initial:
Telephone
(required):
Business Name (if
used):
Business
Telephone:
Address:
Facsimile
Number:
City: State: Zip Code:
E-mail
Address:
Sponsor
Information
Enroller
Information
Sponsor’s Last Name: First
Name:
Initial:
Enroller’s Last Name: First
Name: Same
as Sponso r
Sponsor’s Business Name
(if used):
Enroller’s Business Name
(if used):
Sponser's Address:
Enroller's Address:
City: State: Zip Code:
City: State: Zip Code:
Sponsor’s ID Number:
(required):
Enroller’s ID Number:
(required):
Sponsor’s Telephone
(required):
Enroller’s Telephone
(required):
Payment
Check Information
Credit Card Information
Name on
Check:
Credit Card Number: Expiration
Date:
Check Number:
Name of Card Holder as it
appears on credit card:
Bank Name:
Billing Address (If
different from Application Address):
I, the undersigned,
have read the reverse side of this application and agree to abide by these
as well as all of the Youngevity Policies and Procedures. I understand and will accept the
consequences of violation of the Youngevity Policies and
Procedures.
I, the undersigned, hereby authorize
Youngevity to charge my credit card specified above in the amount of
$10.00.
Print a Copy
for your Records
If you are using this
electronic form for payment information, please be sure to print a copy,
sign it and fax a copy to:719.685.5435
