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Preferred Customer Application Payment Method Visa MasterCard Discover _________________________________________ Card Number _________ /____________ __________________ EXP. (MO/Year) Security Code _________________________________________ Name on Card _________________________________________ Billing Address _____________________ ______ ___________ City ST/Prov. Zip/Postal Code _________________________________________ Signature of Cardholder Referral Website Information Choose a name for your branded Nerium referral website Example: www.yourname.neriumproducts.com __________________________________ __________________________________ Option 1 Option 2 This will also be your username for logging in to your personal account. Retail customers will use your email address to place orders. Choose a Password ______________________________________________________________________________________ Password must consist of letters or numbers only. Must be 4-15 characters in length. Take advantage of our 3UR Free program. Simply sign up three active Preferred Customers in the Auto-Delivery Order program, and you’ll get your next month’s Auto-Delivery Order of NeriumAD Age-Defying Treatment for free! I authorize Nerium International ™ to charge the above named account for the purchase option selected. I understand that Nerium International will apply applicable taxes and shipping and handling charges to my order. An Auto-Delivery Order is included in this purchase option. I authorize Nerium International to ship/charge for these products monthly. Cancellation must be submitted in writing at least five (5) business days prior to the Auto-Delivery billing cycle date. I understand that all financial transactions are in US Dollars. Preferred Customer Signature: ______________________________________________________ Date: ____________________________________ All signatures to this application must be affixed personally. Applicants must be of legal age. I would like to become a Nerium International Preferred Customer and receive my product every month at a discounted price. Shipping and handling and applicable sales tax will be added to my total order at the time it is processed. Please enroll me in the Auto-Delivery Order Program. My Auto-Delivery Order will be processed and shipped starting next month, on the same day of the month that this original order is processed. If that day falls on a weekend or holiday, the order will be processed on the last business day prior. The payment method used for my initial enrollment will be used for my Auto-Delivery Order. The product order I receive will be shipped monthly. Signature: ____________________________________________________________________ Save $30-45 USD per order as a Preferred Customer! Fax to: 214.390.9988 ©2013 Nerium International ™ , LLC. All Rights Reserved. Revised 9/13. Who Introduced You to Nerium? ______________________________________________________________________________________ Nerium ID Number or Username _______________________________________________ _____________________________ _______ Name (First, Last) City ST/Prov Personal Information _____________________________________________________________________ _______________ Name (Last, First, Middle) Date of Birth (optional) ______________________________________________________________________________________ Business Name (if applicable) ______________________________________________________________________________________ Shipping Address (Must be a physical address. Cannot ship to a P. O. Box) _______________________________________________ _______ ________________ __________ City ST/Prov Zip/Postal Code Country __________________________________________ __________________________________________ Email Phone Number (check one: cell home) Purchase Product Quantity Description Auto-Delivery Preferred Customer Price: Total NeriumAD Age-Defying Treatment $80/Bottle of night cream NeriumAD Combo Pack $120/Pack of day and night cream NeriumAD ® Age-Defying Treatment NeriumAD products are developed from the patented extract of the Nerium oleander plant. They contain the most effective age-defying ingredients, chosen for both their individual and synergistic benefits. These premium ingredients are blended at optimum levels to nourish your skin and provide real results.
