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Cosway USA Inc. (“eCosway”) 1300 Clay St. STE 600, Oakland, CA 94612 Phone number: (949)383-7772 Website: www.ecosway.com/US VIP Shopper Application and Agreement A) Sponsor Information: ID Number: Name: ________________________________________ (First Name) ________________________________________ (Last Name) B) Applicant’s Information: Name: ___________________________________________________ (First Name) ___________________________________________________ (Last Name) C) Contact Information: Mailing Address: ___________________________________________________ Street Address | Apt # ___________________________________________________ City | State | Zip Code Email Address: Mobile Number: – – Home Number: – – Social Security Number (Optional) – – D) Registration Fee: (Check one) Payment Mode: *Cash or Credit Card $20.00* FREE MEMBERSHIP with my $50.00 retail purchase I have carefully read the Terms and Conditions on the back of this Application and Agreement and the eCosway Policies and Procedures, and agree to abide by all Terms set forth in these documents. I understand that I have the right to terminate my eCosway VIP Shopper status at any time with or without reason by sending written notice to the Company at the above listed address. By signing below, I certify that I am of legal age (the age of majority) in the state which I reside. I further certify that I have not been an eCosway IBO or VIP Shopper, or a partner, shareholder, or principal of any entity having an eCosway business within the past three (3) months. I understand that any intentional misrepresentation of any information I provide on this VIP Shopper Application and Agreement may result in action by eCosway up to and including termination of this Agreement. __________________________________ Applicant’s Signature __________________________________ Date FOR OFFICE USE ONLY Date Received: Member ID US Reminder to clip a copy of registration invoice together with the office copy. Member ID:
