You are on page 1of 3

Distributorship / Independent Dealer Registration Form

Membership No.: _________


_____________________ ______________ _______________________
First Name Middle Name Last Name
Were you introduced to Health Watch by an existing Dealer? Y / N __________
If yes, his/her full name: ________________________
His/her Membership #: _______________
Tel # (Landline):____________________Tel # (Cell phone):_________________
Email Address:_____________________________________________________
Home Address: ____________________________________________________
_________________________________________________________________
Birth Date (mm/dd/yy): ____/____/____ Sex (M/F): ________ Marital Status:____
TIN #: ____________________________ SSS #: _________________________
Present Occupation: _____________________Employer: ___________________

( ) I understand that the Registration Fee is $100, which includes a Sales Kit
and catalogs.

I _______________________________________ VERIFY THAT ALL THE


INFORMATION
CONTAINED HEREIN IS TRUE AND CORRECT

Signed: ____________________________________________
Date:_______________

Proof of ID, Address verified by ______________ DL # ____________________


Client of ________________ _ Interviewed by __________________
Encoded by ___________________
Comments ________________________________________________________

Health Watch Distributed By Siegranz World Synergy


341 N. Buena Vista Burbank California 91505
Contact Numbers: (805) 308-3903 (818) 636-0668
Webiste: healthwatchcare.webs.com Email: healthwatch@siegranz.com
Independent Dealer Contract Terms & Conditions
This Agreement, made this ____ day of _______________, year _____ between
Siegranz World Synergy Inc. (“SWSI”) and ____________________(“Dealer”)
WITNESSETH THAT:

SWSI agrees that the Dealer may purchase the products of SWSI at prices determined
by SWSI, which are below the retail price, subject to SWSI policies regarding sales,
marketing and payment.

The Dealer represents and warrants that all the information he/she has given in this
Application Form and Agreement is true and accurate.

The Dealer agrees:


a) To obtain and maintain all permits and licenses necessary for the continuance
of his/her business
b) To ensure that he/she complies with all applicable laws governing his/her
business including payment of any and all taxes.
c) To pay for all his/her purchases in accordance with the payment policies of
SWSI without the need for SWSI to demand payment.
d) As far as the law allows, to hold SWSI, its officers and employees free and
harmless from any claim, expense, liability, suit or demand arising from the
conduct of his/her business.
e) To immediately inform SWSI of any change in his/her personal information
given in this Application Form.
f) Not to sell SWSI products in or to retail stores, supermarkets or other fixed
places of business including online without prior written permission from SWSI.
h) TO STORE THE PRODUCTS AWAY FROM SUNLIGHT AND BELOW 86
DEGREES FARENHEIGHT AT ALL TIMES IN ORDER TO PRESERVE THE
QUALITY OF THE PRODUCTS. Failure to do so will cause irreparable damage
to the products such as loss of fragrance, separation or discoloration which will be the
Dealer’s liability.
i) To never leave the products in a vehicle or any other place that may be subject to
heat, and to accept liability for any change in the quality of products not properly stored
in accordance with these directions.
SWSI and the Dealer agree:

a) That this Dealer Agreement does not make the Dealer an employee or agent
of SWSI. The Dealer is an independent businessperson.
b) That this Agreement does not give the Dealer authority to enter into any
agreement or contract with any party by representing himself/herself as an
employee or agent of SWSI or commit SWSI to any contract or agreement
Health Watch Distributed By Siegranz World Synergy
341 N. Buena Vista Burbank California 91505
Contact Numbers: (805) 308-3903 (818) 636-0668
Webiste: healthwatchcare.webs.com Email: healthwatch@siegranz.com
with any third party.
c) That this Agreement does not confer authority to the Dealer to use any of the
trademarks or trade names owned by SWSI.
d) That the Dealer will abide by all policies of SWSI which may change from time
to time.
e) That SWSI may change its prices, commission, and incentive and credit
policies with regard to the Dealer and may reduce or cancel discounts or other
benefits without prior notice.
f) That either party may terminate this Agreement, with or without due cause, at any
time upon notice to the other. Upon termination, all monies owed by Dealer shall
become immediately due and payable.
g) That in case of dispute arising directly or indirectly from this Agreement,
settlement shall be pursued by either Arbitration or through the proper courts at
the option of SWSI.
h) That this Agreement supersedes any prior agreements between SWSI and
the Dealer.

Signed:
_______________________________________Date:_____________________

Please scan and email all 3 pages of this completed form to healthwatch@siegranz.com
or give it to the nearest distributor in your area.

PLEASE PROVIDE a scanned/faxed copy of a Valid ID and proof of address

Health Watch Distributed By Siegranz World Synergy


341 N. Buena Vista Burbank California 91505
Contact Numbers: (805) 308-3903 (818) 636-0668
Webiste: healthwatchcare.webs.com Email: healthwatch@siegranz.com