DistApplicationForm MY web
DISTRIBUTOR APPLICATION FORM Reliv I.D. No. MY How to establish your Reliv ID: 1. In the first three (3) spaces, enter the first three letters of your family name. 2. In the last six (6) spaces, enter the final six digits in your NRIC.
APPLICANT INFORMATION Have you been a Reliv Distributor previously?
YES
NO
New NRIC No. Company Registration No. / Business (ROB) Registration No.
Spouse (if applying) /Authorised officer’s (for company application) New NRIC No.
Date
FOR OFFICE USE ONLY Order Number
Applicant’s Name / Company Name / Business Name Race
Sex
RCN
E-mail Address
Nationality
Spouse’s Name (if applying) / Authorised officer’s name for company or partnership application
Race
Sex
Nationality
Initial
Date
E-mail Address
Mailing Address Town / City
Postal Code
State
Phone Numbers
Home
Mobile
Office
Bank Information
Bank
Branch
Bank Account No.
SPONSOR INFORMATION
Fax
(As Sponsor, I recommend that the applicant(s) be accepted as an authorised Reliv Independent Distributor with the purchase by the applicant(s) of a Reliv Distributor Kit.) I reviewed with the applicant(s) the provisions of the Reliv Compensation Plan, the Reliv Distributor Manual, the Reliv Policies and procedures as well as ordering procedure to obtain product for resale. I have explained that the applicant(s) may obtain complete, comprehensive, and current information about products and other business practices by attending regularly scheduled sales meeting. I will apply my best efforts to assist and support the applicant(s).
Name
E-mail Address
Reliv I.D. No.
Phone Number
Home
Mobile
MASTER AFFILIATE INFORMATION Name
E-mail Address
Reliv I.D. No.
Phone Number
Home
Mobile
DISTRIBUTOR KIT PAYMENT INFORMATION (Please tick one of the following) RM88.00 (RM) = _________________________
Money Order or Cashier’s Cheque
Please send my Distributor Kit and charge to credit card chosen below: Visa M/C
Card No: Signature (exactly as it appears on card)
Exp. Date
/ Cash
X
APPLICANT’S SIGNATURE
DATE
Banking details for cash payments: CIMB Bank Berhad (Section 52, Petaling Jaya Branch) Reliv International Sdn Bhd (Account No. 1248-0011510-05-8) or Maybank (Ampang Park Branch) (Account No. 514-057161-58-4)
NOTE: IF DISTRIBUTOR KIT IS NOT PURCHASED APPLICATION WILL NOT BE PROCESSED
SPOUSE SIGNATURE (If applying)
DATE
THIS APPLICATION AND AGREEMENT MUST BE SUBMITTED IMMEDIATELY UPON COMPLETION TO: Reliv International Sdn. Bhd. Unit A-05-05, Empire Office Tower Empire Subang, Jalan SS16/1, 47500 Subang Jaya, Selangor Darul Ehsan Email: [email protected] • Office: +603-56388788 • Fax: +603-56135788 DISTRIBUTORS HAVE RELIV’S PERMISSION TO DUPLICATE THIS DOCUMENT • PLEASE REFER TO THE RELIV WEBSITE FOR THE UPDATED FORM
MY 9/13
APPLICANT INFORMATION Have you been a Reliv Distributor previously?
YES
NO
New NRIC No. Company Registration No. / Business (ROB) Registration No.
Spouse (if applying) /Authorised officer’s (for company application) New NRIC No.
Date
FOR OFFICE USE ONLY Order Number
Applicant’s Name / Company Name / Business Name Race
Sex
RCN
E-mail Address
Nationality
Spouse’s Name (if applying) / Authorised officer’s name for company or partnership application
Race
Sex
Nationality
Initial
Date
E-mail Address
Mailing Address Town / City
Postal Code
State
Phone Numbers
Home
Mobile
Office
Bank Information
Bank
Branch
Bank Account No.
SPONSOR INFORMATION
Fax
(As Sponsor, I recommend that the applicant(s) be accepted as an authorised Reliv Independent Distributor with the purchase by the applicant(s) of a Reliv Distributor Kit.) I reviewed with the applicant(s) the provisions of the Reliv Compensation Plan, the Reliv Distributor Manual, the Reliv Policies and procedures as well as ordering procedure to obtain product for resale. I have explained that the applicant(s) may obtain complete, comprehensive, and current information about products and other business practices by attending regularly scheduled sales meeting. I will apply my best efforts to assist and support the applicant(s).
Name
E-mail Address
Reliv I.D. No.
Phone Number
Home
Mobile
MASTER AFFILIATE INFORMATION Name
E-mail Address
Reliv I.D. No.
Phone Number
Home
Mobile
DISTRIBUTOR KIT PAYMENT INFORMATION (Please tick one of the following) RM88.00 (RM) = _________________________
Money Order or Cashier’s Cheque
Please send my Distributor Kit and charge to credit card chosen below: Visa M/C
Card No: Signature (exactly as it appears on card)
Exp. Date
/ Cash
X
APPLICANT’S SIGNATURE
DATE
Banking details for cash payments: CIMB Bank Berhad (Section 52, Petaling Jaya Branch) Reliv International Sdn Bhd (Account No. 1248-0011510-05-8) or Maybank (Ampang Park Branch) (Account No. 514-057161-58-4)
NOTE: IF DISTRIBUTOR KIT IS NOT PURCHASED APPLICATION WILL NOT BE PROCESSED
SPOUSE SIGNATURE (If applying)
DATE
THIS APPLICATION AND AGREEMENT MUST BE SUBMITTED IMMEDIATELY UPON COMPLETION TO: Reliv International Sdn. Bhd. Unit A-05-05, Empire Office Tower Empire Subang, Jalan SS16/1, 47500 Subang Jaya, Selangor Darul Ehsan Email: [email protected] • Office: +603-56388788 • Fax: +603-56135788 DISTRIBUTORS HAVE RELIV’S PERMISSION TO DUPLICATE THIS DOCUMENT • PLEASE REFER TO THE RELIV WEBSITE FOR THE UPDATED FORM
MY 9/13
