Application and Agreement

Distributor Information

NAME

DATE OF BIRTH

SOCIAL SECURITY OR FEDERAL TAX ID NUMBER

ADDRESS

CITY

STATE

ZIP

COUNTRY

PHONE

FAX

EMAIL VERIFICATION

Assumed Names, Corporations, Partnerships, or Trusts — If your business will be owned by a corporation, partnership or trust, or will be operated under an assumed name (e.g., XYZ Enterprises or John Doe & Associates), you must complete a Business Entity Application and submit it with this Application and Agreement.

I have carefully read the Trivani International 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 Trivani independent business at any time, with or without reason, by sending written notice to the Company at the above listed address.

Here by I agree have read the Policies and Procedures and digitally sign

SHIPPING INFORMATION

My shipping address is the same as above