TEMPORARY DISTRIBUTOR APPLICATION FORM

14 May 2010 TEMPORARY DISTRIBUTOR APPLICATION FORM (only for Australian and New Zealand Residents) Date : 14/5/2010 YOUR SPONSOR : 065138946 - JOANNA Please select one of these options: AU$ 27.50 / NZ$ 34.00 - Basic Kit (Organiser plus Free Toothpaste) AU$ 104.00 / NZ$ 127.00 - Health Pack (Starter Pack with Free Toothpaste plus RG90 and GL90) AU$ 110.00 / NZ$ 135.00 - Family Pack (Starter Pack with Free Toothpaste plus RG30, GL30, Soap, Oil, Shampoo, Reishi Gano Tea and Black Coffee) Please ensure you complete all fields marked * Full Name (First and Last Name)* : Date of Birth: (dd/mm/yyyy) 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Address* : 1(One) of the phone number must be filled. Phone# : Mobile# : State* : ACT NSW NT QLD SA TAS VIC WA Other Office# : Post Code * : Fax# : Country* : Australia New Zealand Email address : BANK INFORMATION ( Bank Information for monthly bonus purpose) : BSB : - 6(six) digits BSB Account No. : 9(nine) digits Account No. Suffix : 4(four) digits suffix only for New Zealand member A/C Name : Bank Name : Branch : GST STATUS ADVICE: ( Only for Australian ) I/We advise that my/our DXN Distributorship is operated as a hobby or private pursuit only. I have registered my DXN Distributorship for an Australian Business Number (ABN) and ACN if applicable. My ABN is: (must be 11 digits) and my ACN is: I have registered my DXN Distributorship for the Goods and Services Tax (GST). PAYMENT INFORMATION : Credit Card Type* : MasterCard Visa American Express Cardholder's Name* : Credit Card No.* : (number only,without space) Credit Card Exp. Date* : 1 2 3 4 5 6 7 8 9 10 11 12 20102011201220132014 mm/yy ADDITIONAL MESSAGE: (max: 300 characters) Characters Left I declare my application as a distributor of DXN International (Australia) Pty. Ltd. I have fully understood the privileges and responsibilities as a distributor and agreed to be bound by the Code of Ethics and Rules and Regulations of the Company. I agreed that the Company shall terminate my distributorship for any violation of the code of Ethics and the Rules and Regulations of the Company. The above Statement shall not imply that I am an employee or representative of DXN International (Aust) Pty. Ltd. for accessing e-mail me first randylorenzo22@yahoo.com to assist you this is temporary registration for australia Copyright © 2010 DXN International (Australia) Pty. Ltd. All Rights Reserved.