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DIRECT DEPOSIT AUTHORIZATION FORM

DATE: (Month/Day/Year) TO: HERBALIFE INTERNATIONAL PHILIPPINES, INC. FAX NO. (632) 899 5005

I, (Distributor's / Depositor's Name )

with Herbalife I.D. #

request HERBALIFE INTERNATIONAL PHILIPPINES, Inc. to process the following order(s) paid for by the bank deposit I transacted with ( Name of Bank/Branch ) for the total amount of P

Name of Purchaser / ID NO. on Order Form

TOTAL VOLUME POINTS

TOTAL AMOUNT

ORDER NUMBER

Complete order forms and copy of the deposit slip are attached.

SIGNATURE :

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