Distributorship Agreement

401- 404 Dynasty Business Park • B – Wing, Level – 4 • Kanakia Spaces,

Andheri-Kurla Road, Andheri (East), Mumbai – 400 069

Applicant Information

Name (Last, First, Middle Initial) or Business Name PAN

M F
Co-Applicant/Spouse Name (Last, First, Middle Initial) (if applicable) Birth Date (DD/MM/YY) Gender

Street Address (Current Mailing Address) STD Code Home Phone Number

City State PIN Code STD Code Work Phone Number

E-mail
E-Mail Address Mobile Phone Number

Sole Proprietorship Partnership Corporation Husband/Wife Co-Applicants

STD Code Fax Number

Sponsor Information The Sponsor is the Distributor who is the immediate upline of a Distributor.

Distributor ID Number Sponsor Name STD Code Daytime Phone Number

Membership and Order Payment Information

Please accept my payment of the `900 fee plus any applicable VAT and shipping/handling.

MasterCard
®
American Express®
Credit Card Expiration Date (MM/YY) CVC

VISA ®
Cash/money order
Cardholder’s Name (Last, First, Middle Initial)

Item Number Product Description Quantity PV Unit Price Total PV Extended Price

Bank Information (to receive commision payments)

Full Name of Bank Branch Bank Branch Indian Financial System Code (IFSC)

Full Address of Bank Branch

Full name of account holder(s) as stated on bank account

Bank Account Number

Bank/Branch Pin Code Bank Swift Code

By signing and submitting this form and payment of my Distributorship fee, I acknowledge that I am applying to become a Unicity Distributor. I consent to Unicity contacting me at the
telephone numbers, fax number, and/or e-mail address listed on my application or as updated. I certify that I have read and agree to the Terms and Conditions on the reverse side of
this form. I further certify that I have received, have read, understand, and agree to the Unicity Award and the Unicity Policies & Procedures, which are incorporated herein and made
part of this Agreement.

Applicant Signature Date (MM/DD/YY) Co-Applicant/Spouse Signature Date (DD/MM/YY)

© 2011 Unicity International Distributors and applicants may photocopy this form or download it from www.unicity.net/india. ID 0311