Product Order Form Presented by 2400 Boswell Road, Chula Vista, CA 91914 (619) 934-3980 Office • (619) 934-3205 Fax (800) 982-3197 Orders • (800) 982-3189 Customer Service
An Independent Marketing Director
www.YOUNGEVITY.com
Ship To: ( if different )
Ordered By: Name
ID#
Name
Address
ID#
Address
City
State
Zip
City
Phone
Phone
State
Zip
Yes, this is my qualification order for (circle one): January
February
March
QTY
CODE#
April
May
June
July
August
September
BV
PRODUCT DESCRIPTION
METHOD OF PAYMENT Cash
Check
Money Order
Credit Card
October
Total
November
PRICE
Sub Total $ Standard Shipping $
Youngevity® Debit Card
(8% of Sub-Total or $6.50 min., whichever is greater - Continental U.S.) For expedited shipping, please call for current rates.
Applicable Sales Tax for Shipping Address $
Exp. Date: Card #:
Total Remittance $
CVV code:
(3 digit number = VISA®, MasterCard® and Discover® branded credit and debit cards. 4 digit number = American Express® branded credit or debit card.)
FOR OFFICE USE ONLY
Name on Credit Card: Mailing Address
(if different from above):
I authorize Youngevity® to charge my credit or debit card. Authorized Signature: ©2016. Youngevity® (MOD0216) #90202
December
TOTAL
ACTION DESIRED (CHECK BOX):
Reason for the Return:
☐ Damaged merchandise ☐ Exchanging for other products ☐ Incorrect products received
Detail Actions on how to process your return:
☐ Returning products for a refund ☐ Unsatisfied with product ☐ Changed mind and wants refund
Mandatory ID #:
☐ Allergic reaction
Name:
☐ Already have product in stock
Phone:
(Please describe on the right)
Email: