Product Order Form

1607 E Big Beaver Rd Suite #110, Troy, MI 48083 Customer Service 1.877.VISALUS

Fax Form To: 877.547.1570

Balance Kit
$77 Retail Value

Save $28

Auto-Ship Price

49

Shape Kit
$144 Retail Value

Save $45

Auto-Ship Price

99

1 Pouch Vi-Shape Nutritional Shake Mix 5 Packets Shape-Up Health Flavor Mix-Ins

2 Pouches Vi-Shape Nutritional Shake Mix 10 Packets Shape-Up Health Flavor Mix-Ins

Core Kit
$287 Retail Value 1 1 5 2

Save $88

Auto-Ship Price

199

Transformation Kit
$349 Retail Value 2 10 1 1 1 2

Save $100

Auto-Ship Price

249

Vi-pak (30 daily AM/PM packets) Pouch Vi-Shape Nutritional Shake Mix Packets Shape-Up Health Flavor Mix Ins Boxes ViSalus NEURO: one each Raspberry Boost and Lemon Lift

Pouches Vi-Shape Nutritional Shake Mix Packets Shape-Up Health Flavor Mix-Ins Bottle Vi-Slim Metab-Awake! Tablets Box Vi-Trim Clear Control Drink Mix Bottle Omega Vitals Supplement Boxes ViSalus NEURO: one each Raspberry Boost and Lemon Lift

Add the full Vi-pak to your Challenge Kit (Auto-Ship Only)

Only $99
pRoDUCT DESCRIpTIoN WHoLESALE RETAIL $49 $99 $199 $249 $99 $45 $28 $34 $34 $125 $125 $125 $40 $40 $10 $10 $12 $12 $12 $50 $125 $125 $24 $24 $63 $63 $61 $124 $249 $311 n/a $59 $35 $41 $41 $150 $150 $150 $50 $50 $12.50 $12.50 $15 $15 $15 $63 $150 $150 $30 $30 $75 $75 qTy ToTAL AUTo-SHIp
5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH

ITEM No. K0020 K0021 K0019 K0015 N1210 N1211 N1227 N1228 K0029 K0030 K0028 N1212 N1213 N1214 N1215 N1216 N1217 N1218 K0010 N1002 N1001 N1070 N1071 N1073 N1074

Body by Vi Balance Kit Body by Vi Shape Kit Body by Vi Core Kit Body by Vi Transformation Kit Add Vi-pak to your Challenge Kit (Auto-Ship only) Vi-Shape Nutritional Shake Mix (30 Serving Pouch) Vi-Shape Nutritional Shake Mix (15 Individual Packets) Nutra-Cookie Chocolate Chip (14 Individually Wrapped Cookies) Nutra-Cookie Oatmeal Raisin (14 Individually Wrapped Cookies) Nutra-Cookie Chocolate Chip 4-Pack (4 boxes) Nutra-Cookie Oatmeal Raisin 4-Pack (4 boxes) Nutra-Cookie Variety 4-Pack (2 boxes each Chocolate Chip and Oatmeal Raisin) Vi-Slim Metab-Awake! Tablets (60 Tablets per Bottle) Vi-Trim Clear Control Drink Mix (30 Individual Packets) Shape-Up Health Flavor Mix-In Strawberry (15 Individual Packets) Shape-Up Health Flavor Mix-In Chocolate (15 Individual Packets) Shape-Up Health Flavor Mix-In Banana (15 Individual Packets) Shape-Up Health Flavor Mix-In Peach (15 Individual Packets) Shape-Up Health Flavor Mix-In Orange (15 Individual Packets) Health Flavor Mix-In Variety 5Pack (1 box of each flavor) Vi-pak (30 Daily AM/PM Packets) Vi-pak Sample Pack (10 ThreeDay Samples AM/PM Packets) ViSalus NEURO Raspberry Boost Drink Mix (15 Packets) ViSalus NEURO Lemon Lift Drink Mix (15 Packets) ViSalus NEURO Raspberry Boost Drink Mix (42 Serving Jar) ViSalus NEURO Lemon Lift Drink Mix (42 Serving Jar)

Side 1 Sub-Total

Form continues on reverse

2010 ViSalus Sciences All Rights Reserved. Revised D1001US-15 1/2

Product Order Form

ITEM No. N1221 N1222 N1223 N1224 N1219 N1220 N1050 T2015 T2016 T2017 T2018 T2019
SHIPPING SCALE Order Total From To $0 $0.99 $50.01 $150.01 $300.01

1607 E Big Beaver Rd Suite #110, Troy, MI 48083 Customer Service 1.877.VISALUS

Fax Form To: 877.547.1570

pRoDUCT DESCRIpTIoN Anti-Aging & Energy Supplement (30 Capsules per Bottle) Supercharged Antioxidant Supplement (30 Tablets per Bottle) Multi Mineral & Vitamin Supplement (60 Tablets per Bottle) Omega Vitals Supplement (60 Softgels per Bottle) Deter-mints Lemon Pomegranate (30 Chewable Tablets per Bottle) Deter-mints Wintergreen (30 Chewable Tablets per Bottle) Vimmunity BBV Shaker Cup BBV Tape Measure BBV Pedometer BBV Shaker Cup / Program Guide / Journal Combo BBV Shaker Cup / Tape Measure / Pedometer Combo
Shipping $0 $6 $10 $14 $19 Order Total From $500.01 $2490.00 $4990.00 $9990.00 Shipping To $2489.99 . . . . . . $4989.99 . . . . . . $9989.99 . . . . . . ........... $25 $50 $80 $125

WHoLESALE $44 $34 $24 $34 $25 $25 $28 $9 $5 $7 $10 $19

RETAIL $55 $42.50 $30 $42.50 $31.25 $31.25 $35 $9 $5 $7 $10 $19

qTy

ToTAL

AUTo-SHIp
5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH 5TH 12TH 19TH

Side 1 Total Date Ordered: / /

Check one date for each individual product you would like AutoShipped to you each month.

$0.99 . . . . . . . . . $50.00 . . . . . . . . $150.00 . . . . . . . $300.00 . . . . . . . $500.00 . . . . . . .

NOTE: Tax and Shipping & Handling will be added to total.

ViSalus Auto-Ship Advantage program

Retail Price: Price for customers who want the product one time. Distributor Wholesale Price: Price for distributors and Auto-Ship Advantage Program customers. *Please note: it is against ViSalus policy to sell any ViSalus product below its wholesale price. See www.visalus.com for up-to-date product information and additional items.
Choose the Auto-Ship Program to guarantee you never run out of product. Initial orders will be processed and shipped upon receipt. Auto-Ship orders will be processed & shipped starting next month on the selected date. Auto-Ship orders will be processed on the last business day before a weekend or holiday. Changes to Auto-Ship orders must be received at least 5 days prior to Auto-Ship date. Customers who select Auto-Ship are Preferred and can receive Wholesale pricing.

Customer Shipping Information

Last Name: _______________________ First Name:______________________

Customer Billing Information

Full Name on Credit Card: _____________________________________________ Billing Address: ___________________________________________________ Apt/Suite: ______________________________________________________ City: ___________________________ State: ______ Zip: ______________

Shipping Address:__________________________________________________ Apt/Suite: ______________________________________________________ City: ___________________________ State: ______ Zip: ______________

Daytime Phone #: __________________________________________________ E-mail Address: ___________________________________________________ and promotions.

Credit Card Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Expiration Date: ____________________ Card Type: Visa MasterCard Security Code: ____________________ American Express

Yes, I would like to receive communications from ViSalus regarding special discounts

Discover

Fill in the Name and ID number of the ViSalus Customer or Distributor signing you up today: Last Name: _______________________ First Name:______________________

Cardholder Signature: _______________________________________________

I authorize ViSalus Sciences to charge my account for the amount listed. I promise to pay such amount to and in agreement governing the use of such card. I understand that ViSalus Sciences will apply Taxes, Shipping and Handling charges to my order. If order is Autoship, I authorize ViSalus to ship these products monthly. Cancellations must be submitted 5 days prior to the Auto-Ship date.

ID # or SSN:______________________________________________________

Fax Order to 1.877.547.1570, call 1.877.VISALUS, or place order online at www.visalus.com

2010 ViSalus Sciences All Rights Reserved. Revised D1001US-15 2/2