Member and Distributor Agreement (U.S. Version)

Member and Distributor Agreement (U.S. Version)
Member Information
First Name:
Middle Initial:
Last Name:
Home Address:
Apt./Ste.#:
City:
State:
Zip:
If Your Shipping Address is Different from Above, Fill out Shipping Information Below.
Ship Address:
Apt./Ste.#:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
Cell Phone:
Email Address:
Date of Birth:
Social Security Number:
Sponsor ID (if sponsored):
AutoPay Options Select One: ">Credit Card ">Direct Debit ">PayPal
My Credit Card is a:
MasterCard Visa
Credit Card #:
Security Code:
Expiration Date
First Name on Credit Card:
Middle Name on Credit Card:
Last Name on Credit Card:
Enter Billing Address if Different from Home Address:
Direct Debit From Bank Account
Name(s) on Account:
Account Number:
Bank Name:
Bank Routing Number:
Bank Address:
PayPal Account
Please Enter Your PayPal ID/E-mail Address:
Acknowledgement
AHL is hereby authorized to charge or debit (unless otherwise instructed) the stated credit or bank account each four week cycle the amount of $199 plus tax (if applicable), plus shipping and handling.

I understand that the only financial obligation required by AHL to become a member is the agreement to purchase one case of AHL''s drinks per the turn of the four week cycle. There are no initiation fees to join and n oother fees due to contunue. Taxes (where applicable), whipping and a handling fee will be added to each order. My first order will be processed upon approval of this application and subsequent orders will fall in the regular AutoPay billing and shipping cycle. I have read and agree to the terms and conditions of this agreement and all other terms and conditions (attached hereto) and the Policies and Procedures found [here].

Under penalty of perjury, I certify that:
  1. The number shown on this form is my correct social security number and
  2. I am not subject to backup withholding income because:
    (a) I am exempt from backup withholding, or
    (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or, (c) The IRS has notified me that I am no longer subject to backup withholding*; and
  3. I am a U.S. Person (including a U.S. Resident Alien).


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Sylmar, CA 91392
818-364-2902
818-833-8983 (fax)