Enagic United states
Finance Application Form

Referenced documents: Enagic United States Finance Authorisation to Pay Form

Are you currently an Enagic distributor

Enagic ID #

First name

Middle name

Last name

Drivers license

State

Date of birth

Mailing Address (must match W9)

Address

City

State

ZIP Code

SS#

Phone number

Cell number

Fax number

Email address

Billing address (if different from mailing address)

Address

City

State

ZIP Code

Shipping address (if different from mailing address)

C/O

Phone number

Address

City

State

ZIP Code

Delivery method

Enroller and sponsor infomation (if applicable)

Enroller name

Enroller ID

Phone number

Sponsor name

Sponsor name same as above

Phone number

Under sponsor ID number

Item ordered

Product retail price

Payment amount

Enagic payment

Handling

Tax

Shipping

Down

Total down

Employer name

City, State

Phone number

Income

**Please note the first payment date must be within 45 days from purchase date. Payment must be on the first or the 15th of each month.

Finance amount

Monthly payment amount

Withdrawal date

First payment date

Credit card information

Payment method (no Diner's cards)

Cardholders name

Credit card number / Checking account number

Expiration date / Checking account routing number

CVV#

Cardholder signature

Clear

* Please fill out Alternate Payer Form if someone beside the applicant will be making down payment and/or monthly payment. *

Applicants name

Applicants signature

Clear

Date

Enroller Name

Who is your DBS specialist?

Enagic United statesFinance Application Form

Mailing Address (must match W9)

Billing address (if different from mailing address)

Shipping address (if different from mailing address)

Enroller and sponsor infomation (if applicable)

Payment amount

**Please note the first payment date must be within 45 days from purchase date. Payment must be on the first or the 15th of each month.

Credit card information

*** Please fill out Alternate Payer Form if someone beside the applicant will be making down payment and/or monthly payment. ***

Enagic United states
Finance Application Form

* Please fill out Alternate Payer Form if someone beside the applicant will be making down payment and/or monthly payment. *