NUTRITION FOR LIFE INTERNATIONAL
Last Name ____________________ First Name __________________ Initial ________
Address ______________________ City _____________ State _________ Zip ______
Telephone _________________________ Social Security Number _________________
Name: Sam Pieprzyca
Address: 21602 Longwood, San Antonio, TX 78259
Telephone: (210) 497-7869 ID: 45-0539054
If a product purchase accompanies this agreement and you are a resident of California, South Dakota, Texas, Utah or Wisconsin you must add the appropriate sales tax. Hawaii & Alaska charged 2nd Day shipping - PLEASE CALL 1-800-800-7377 FOR INFORMATION.
___ YES! I want to be an independent Nutrition For Life distributor! I have read everything on the front and back of this form and understand all of my options. I also understand that there is a 10% restocking fee should I decide to return any unopened product I purchase.
Signature _____________________________ Today's Date ______________________
Visa#/MC#/Discover#/AmEx# _______________________________ Exp.
(or check enclosed for the appropriate amount, made payable to Nutrition For Life)
FAX this application to: (713) 460-8599
FED EX this application to:
Nutrition For Life
9101 Jameel, Houston, TX 77040
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