SYNERGY 4-in-1 Member Starter Form

WorldWide 5152 N. Edgewood Dr. Suite 200 • Provo, Utah 84604 USA
Phone (801)431-7660 • Fax (801)494-5195 • www.synergyworldwide.com

1 . A PPLICANT INFORMATION
PHONE TODAY’S DATE
MOBILE
FAX
SOCIAL SECURITY # / BUSINESS ENTITY ID # E-MAIL ADDRESS

NAME (LAST, FIRST, MIDDLE) OR NAME OF BUSINESS ENTITY YOUR SYNERGY CUSTOMER SERVICE REP

CONTACT NAME (IF DIFFERENT) SYNERGY ID# WEBXPRESS PASSWORD

SHIPPING ADDRESS CITY / PROVINCE STATE / COUNTRY ZIP / POSTAL CODE

BILLING ADDRESS (IF DIFFERENT) CITY / PROVINCE STATE / COUNTRY ZIP / POSTAL CODE

SPONSOR NAME (LAST, FIRST, MIDDLE) SPONSOR ID NUMBER

SELECT ONE OPTION Incorrect or incomplete information could delay the processing of this application

1 Automatically Place Under Sponsor Tracking Center 1 2 3 Linkage L eft Right

2 Place Under The Following Team Member Tracking Center 1 2 3 Linkage L eft Right

PLACEMENT UPLINE ID NUMBER PLACEME N T U P L I N E N A M E ( L A S T, F I R S T, M I D D L E )

2 . ACTIVATING ORDER Order Number: 1 TC 3 TC

Item # Description Quantity CV Total Wholesale

SUBTOTAL: SALES TAX: SHIPPING: TOTAL

3 . R ESALE ORDER Order Number: Place Under: 1 TC 2 TC 3 TC

Item # Description Quantity CV Total Wholesale

SUBTOTAL: SALES TAX: SHIPPING: TOTAL

4 . AUTOSHIP ORDER Template Number: Autoship Date:

Item # Description Quantity CV Total Wholesale

SUBTOTAL: SALES TAX: SHIPPING: TOTAL

Visa Mastercard AmEx Discover CC# EXP: /

I hereby authorize Synergy WorldWide to charge my credit
card for any order I place or for the amount of the Autoship
order I have established. I understand that these order(s) may
include shipping fees and sales tax. In the event a charge is
dishonored for any reason, I agree to pay a $20 service fee.
I have read and agree to the Terms and Conditions contained on the reverse side of this document and I am familiar with
the return policy described in the company’s Policies and Procedures manual. I hereby agree to be bound by the Terms
and Conditions, which by reference are fully incorporated into this agreement. I certify that I am the age of majority and
am legally able to enter into this contract. I have read and agree to the company’s Policies and Procedures and agree to
the terms of confidentiality contained therein. I UNDERSTAND THE RESALE PRODUCT PURCHASES ARE OPTIONAL.
INITIAL

N A M E ON CREDIT CARD APPLIC A N T ’ S D AT E A U T H O R I Z E D

SIGNAT U R E

USA ENGLISH • REV1204

TER M S A N D C O N D I T I O N S :

This Agreement is entered into between the APPLICANT, named above (hereafter “APPLICANT”) and SYNERGY
WORLDWIDE. The parties agree:

APPLICANT hereby applies as a Team Member (Independent Distributor) in SYNERGY WORLDWIDE’S Independent
Distributor Program. For a period of 21 days from the mailing of this Application, or until such time as SYNERGY
notifies APPLICANT of this Application’s acceptance or rejection, APPLICANT is authorized as a Team Member
(Independent Distributor) and granted the rights to sell SYNERGY products. SYNERGY reserves the right to accept or
reject any application for any reason, in accordance with the terms and conditions set forth in the SYNERGY Policies
and Procedures, as such now exists or may hereafter be amended.

By submitting this application and any order associated with it, I attest that the information contained in it is complete
and true, and that I am at least 18 years of age. I understand that no product purchase or other payment is required to
become a Team Member. As a Team Member, I may buy and sell SYNERGY products and advance through SYNERGY’s
Leadership System. I understand that this application/order is binding upon me as a Team Member. I agree to comply
with SYNERGY’s Policies and Procedures as they are currently written and found in the Policies and Procedures manual
online and in the published booklet and as they may be amended by SYNERGY.

Any Team Member may cancel their membership at any time by submitting their resignation in writing to Synergy
WorldWide, 5152 N. Edgewood Dr. Suite 200, Provo, Utah 84604. Synergy WorldWide is a division of Nature’s Sunshine
Products, Inc.