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First Name: *

Last Name: *

Email Address: *

Mailing Address: *

Best phone# to reach you: *

Social Security# *

Do you currently have a Sales Tax ID# *

Yes No

Option: Elishea LLC will collect taxes on sales and submit to the State if you do not intend to obtain a tax ID. Please initial if you agree

Distributors will be required to purchase a distributor kit at wholesale cost plus tax which is half the retail price. This is non-refundable. You will be asked to sign a distributor agreement with Dr. Elisha to follow and will outline specifics.

Your Signature: *

Date: *

Dr. Esther Elisha Owner-Elishea LLC

Date: *