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  • 1. VISALUS ™ CUSTOMER APPLICATION Fax Form to 1.877.547.1570 FIT KIT NEW SHAPE KIT $299 Auto-Ship Price $99 Auto-Ship Price $409 Retail Value SAVE $110 $136 Retail Value SAVE $37 Supports athletic performance. Shape your body. Benefits: 60 Full Meals! Benefits: 60 Full Meals! • Healthy energy, stamina, endurance • Two shakes per day for faster results • Supports lean muscle • Includes samples of each of our Shape-Up™ Health Flavor Mix-Ins TRANSFORMATION KIT BALANCE KIT $249 Auto-Ship Price $49 Auto-Ship Price $339 Retail Value SAVE $90 $68 Retail Value SAVE $19 Ultimate shaping and nutrition support. Balance your nutrition daily. Benefits: 60 Full Meals! Benefits: 30 Full Meals! • Comprehensive support for your goals • The shake mix that tastes like a cake mix™ • Appetite and metabolism support • Proprietary Tri-Sorb™ protein blend • Supports lean muscle and the body’s fat burning process • Supports digestive, heart and bone health • Supports digestive, heart and bone health • Includes samples of Shape-Up™ Health Flavor Mix-Ins CORE KIT Add Vi-pak® Only $99 $199 to your kit Auto-Ship (Auto-Ship Only) Price $278 Retail Value SAVE $79 Support your active lifestyle. Benefits: 30 Full Meals! • Energy, stamina and hydration NEW! Yes! Auto-Ship My Order. • Molecularly-distilled Omega Oils ViSalus GO™ • Chelated Multi-Mineral & Vitamin Check one date: ViSalus PRO™ • Supercharged Antioxidant with a powerful blend of 26 of nature’s richest sources • Patented Anti-Aging & Energy formula 5th 12th 19th • Contains ViSalus NEURO® for healthy energy and Shape-Up™ Health Flavor Mix-Ins Add nutra-cookies™ Only $34/box Add New ViSalus GO™ Add New ViSalus PRO™ to your order Auto-Ship Price to your order to your order Chocolate Chip Oatmeal Raisin Peanut Butter Only $48/box Only $32/box Auto-Ship Price Auto-Ship Price 3 FOR free To qualify for your FREE Kit, the 3 (or more) orders must be Challenge Kit Customers (not Promoters) with a total sales volume SCHEDULE MY of at least three times that of your personal Challenge Kit. All 3 orders must CHALLENGE As a Body by Vi™ Challenge Kit Customer or Promoter, simply use your ID # and your personal BodyByVi.com website to refer at least be on Auto-Ship, and be placed within the same calendar month. Limited to one free Kit per person per month. Tax, shipping PARTY FOR 3 other Customers to a Challenge Kit and you could get your Kit for and handling still apply. Date: free next month.Customer Shipping Information: Customer Billing Information:Last Name:________________________ First Name:_______________________ Full Name on Credit Card:____________________________________________Shipping Address:___________________________________________________ Billing Address:__________________________________________________Apt/Suite:_______________________________________________________ Apt/Suite:_____________________________________________________City: ___________________________ State:_______ Zip:_______________ City: ___________________________ State:_______ Zip:_____________Daytime Phone #:___________________________________________________ Credit Card Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|E-mail Address:____________________________________________________ Expiration Date:_____________________ Security Code:___________________▢ Yes, I would like to receive communications from ViSalus™ regarding special discounts Card Type: ▢ Visa ▢ MasterCard ▢ Discover ▢ American Express and promotions. Cardholder Signature:______________________________________________Fill in the Name and ID number of the ViSalus Customer or Promoter signing you up today: I authorize ViSalus to charge my account for the amount listed. I promise to pay such amountLast Name:________________________ First Name:_______________________ to and in agreement governing the use of such card. I understand that ViSalus will apply taxes, shipping and handling charges to my order. If order is Auto-Ship, I authorize ViSalus to ship these products monthly. Cancellations must be submitted 5 days prior to the Auto-Ship date.ID # or SSN:______________________________________________________ 1607 E. Big Beaver Rd. Suite #110, Troy, MI 48083 • Customer Service 1.877.VISALUS • vi.com © 2012 ViSalus, Inc. All rights reserved. D1053US-08
  • 2. PROMOTER SYSTEMS BECOME A VISALUS™ INDEPENDENT PROMOTER AND START EARNING MONEY & REWARDS when you help people join The Challenge and become Challenge Promoters like you! 49 The basic information you need to start promoting The Challenge! $ + PURCHASE YOUR CHALLENGE KIT x3 FROM $49–$299 499 Experience the most popular Challenge Kit products. Promote The Challenge with premium promoting materials and samples. Access Exclusive SUCCESS Entrepreneurship & Leadership Audios. And…Jump-start your way to $ Rising Star & Bimmer Club reward opportunities. x15 VISALUS TM 25% off Executive Promoter System required to participate in Rising Star & BMW Programs. TOTAL RETAIL VALUE $ 1,897 The fastest way to become a Rising Star! Enjoy all of the components of the Executive Promoter System…PLUS – 999 arm yourself with additional promoting materials, and Taster & Starter Packs to give those you know a real taste of what The Challenge is all about! $ x40 x10 25% off FREE 25% off VISALUS TM x25 x25 x101607 E. Big Beaver Rd. Suite #110, Troy, MI 48083 • Customer Service 1.877.VISALUS • vi.com© 2012 ViSalus, Inc. All rights reserved. D1028US-16
  • 3. VISALUS ™ INDEPENDENT PROMOTER (VIP) APPLICATION Fax Form to 1.877.547.1570 STEP 1: Join Our Team. Please choose an enrollment option. PROMOTER SYSTEMS $ 49 $499 x40 $ 999 x15 TOTAL RETAIL VALUE $ 1,897 x10 25% off x3 25% off 25% off FREE + PURCHASE YOUR CHALLENGE KIT VISALUS TM VISALUS TM FROM $49–$299 x25 x25 x102 STEP 2: Select Your Monthly Challenge Kit. Choose the items you would like shipped to you each month. NEW CHOOSE YOUR AUTO-SHIP DATE: 5th 12th 19th Executive enrollment Auto-Ship orders will be processed and shipped starting the next month on the selected date. 30 Children’s SHAKE Basic enrollment Auto-Ship orders will be processed and shipped with your Meals Donation $24 FIT KIT TRANSFORMATION KIT CORE KIT SHAPE KIT BALANCE KIT enrollment package. If selected date AUTO lands on a weekend or holiday, orders QTY: SHIP $299 $249 $199 $99 $49 $409 Retail Value $339 Retail Value $278 Retail Value $136 Retail Value $68 Retail Value will be processed on the last business SAVE $110 SAVE $90 SAVE $79 SAVE $37 SAVE $19 day prior. Shake Meal for Meal Match!2 STEP 3: Additional Products 2 STEP 4: Vi-Net® Login & Additional Tools All additional product orders will be processed and shipped with your enrollment package. Please select a unique username and password to access your ViSalus Back Office. QTY ITEM NAME ITEM PRICE AUTO-SHIP ONE-TIME QTY ITEM NAME ITEM PRICE AUTO-SHIP ONE-TIME If neither Username choice is available, Passwords must have 6–16 characters username will default to your mailbox and contain at least one letter and one 50 Taster Packs $250 Nutra-Cookie™: Pick a Flavor number. number, e.g., rsmith2. 25 Starter Packs $250 (1st Choice): Oatmeal Raisin $34/box (2nd Choice): ViSalus GOTM–2 oz. Shots $48/box Peanut Butter $34/box ViSalus PROTM–Drink Mix $32/box Chocolate Chip $34/box You will automatically be Upgrade to Vi-Net Pro subscribed to Vi-Net Pro Swipe for $39/mo and Vi-pak® $99 plus ViSalus Success Club get The Swiper for $49 Subscription for $29/mo. (one time charge) See Product Price Sheet for Item Numbers and pricing information. To change or cancel, call ViSalus Customer Service at 1.877.VISALUS2 STEP 5: Personal Information IP# or SSN:____________________________________________________ Communication Preferences: Enroller Last Name:___________________ First Name:_______________________ Home Phone #:_____________________ Mobile Phone #:________________ The Enroller is an existing IP who refers a new IP. The Enroller can place the new IP anywhere in the depth of his/her organization. Once the enrollment process is complete the enroller can add/change sponsor information in the “Waiting Room” found in Vi-Net. Mobile Phone Provider: Required for ViSalus Mobile Updates (SMS)____________________ E-mail Address:________________________________________________ Last Name:_______________________ First Name:______________________ Receive ViSalus News & Updates via: Check at least one SSN or Tax ID:______________________ Birth Date: ____/ ____/______ ▢ Phone ▢ Email ▢ Mobile Text Message (SMS) ▢ None Company Name:___________________________________________________ If doing business as a legal entity, complete and attach the Company Enrollment Form. (Required) Language Preference: ▢ English ▢ Spanish ▢ Both Gender: ▢ Male ▢ Female Shipping/Mailing Address:___________________________________________ Billing Information: Apt/Suite:_______________________________________________________ Full Name on Credit Card:__________________________________________ City: ___________________________ State:_______ Zip:_______________ Credit Card Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Billing Address:___________________________________________________ Expiration Date:_____________________ Security Code:_________________ Apt/Suite:_______________________________________________________ Card Type: ▢ Visa ▢ MasterCard ▢ Discover ▢ American Express City: ___________________________ State:_______ Zip:_______________ Cardholder Signature:____________________________________________ I authorize ViSalus to charge my account for the amount listed. I promise to pay such amount to and in agreement governing the use of such card. I understand that ViSalus will apply taxes, shipping and handling charges to my order. If the order is Auto-Ship or a monthly Vi-Net Subscription, I authorize ViSalus to ship/charge these products monthly. Cancellations must be submitted at least 5 days prior to the Auto-Ship date or Vi-Net billing date.I understand that to become an Independent Promoter (IP) of ViSalus I am only required to submit this Agreement. receipt of this Agreement. I have read and understand ViSalus’ Policies and Procedures and Compensation Plan,I further acknowledge that my advancement in the ViSalus marketing plan is based solely upon the acquisition of which are incorporated by the reference herein, and agree to abide by them as they may be amended at any time.customers. My purchase of sales aids or training material, or attendance at training classes, is strictly optional andat my discretion. I also understand that if I choose to enroll or sponsor other individuals to participate in ViSalus’ I UNDERSTAND THAT I MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION AT ANY TIME,marketing plan, I will only be compensated based upon the activities of other IPs to the extent of their sales madeto customers. FOR ANY REASON. I UNDERSTAND THAT MY NOTICE OF CANCELLATION MUST BE SUBMITTED IN WRITING TOBy my signature below and initials on the IP Terms of Agreement on the reverse side, I acknowledge that I have THE COMPANY AT ITS PRINCIPAL BUSINESS ADDRESS. PLEASE SEE OTHER SIDE FOR TERMS.carefully read this Agreement, and I am willing to accept the terms and conditions herein and on the reverse side.I understand that the terms of this document shall be a binding Agreement between ViSalus and me and uponApplicant Signature: X Date: This application is not considered complete unless ViSalus receives both the signed and dated Application (page 1) and the initialed Terms of Agreement (page 2) 1607 E. Big Beaver Rd. Suite #110, Troy, MI 48083 • Customer Service 1.877.VISALUS • vi.com © 2012 ViSalus, Inc. All rights reserved. D1000US-25 1/2
  • 4. VIP TERMS OF AGREEMENT Fax Form to 1.877.547.1570By joining ViSalus™ these are the Terms you have agreed to. Refer to the from VISALUS without written authorization and that the unauthorized usePolicies and Procedures for detailed information. of any Proprietary Mark is a violation of federal law and this Agreement,1. I acknowledge that I am of legal age to enter into this Agreement and that constituting grounds for termination of this Agreement by VISALUS. I am a real person. 16. I understand that as a Promoter, I am free to select my own means,2. I understand and acknowledge that this Agreement is not binding until methods and manner of operation and that I am free to choose the hours received and accepted by VISALUS. and location of my activities under this Agreement, subject only to the terms of this Agreement and VISALUS Policies and Procedures.3. I agree that as a Promoter, I am responsible for determining my own business activities and that I am not an agent, employee or legal 17. I acknowledge that I am not guaranteed any income nor am I assured representative of VISALUS. I am responsible for the payment of all federal any profits or success. I certify that no claims of guaranteed profits or and state employment taxes and any other tax required under any federal, representations of expected earnings that might result from my efforts have state or regulatory law. In the event that I fail to provide VISALUS a valid been made by VISALUS or any VISALUS Promoters. In this connection, I Social Security Number or employer identification number, VISALUS may shall not represent directly or indirectly that any person may, can or will withhold commissions due to me until a valid number is provided. earn any stated gross or net amount, nor that sponsorship of others is easy to secure or retain, or that substantially all Promoters will succeed.4. I understand that I am not being sold a franchise or business opportunity. 18. I acknowledge that I have the right to sign up as many personal customers5. I may terminate this Agreement for any reason, at any time, by giving as I wish. I will receive a commission each month from my personal VISALUS prior written notice. VISALUS may terminate this Agreement in customers’ purchases and my downline network in accordance with the writing upon violation of policies and procedures or in the event I violate VISALUS Compensation Plan then in effect. any part of this Agreement. In such event, no further commissions will be paid by VISALUS. To terminate this Agreement, I must mail or deliver 19. I agree to indemnify and hold harmless VISALUS from any and all claims personally to VISALUS, a signed, dated written notice of cancellation sent losses, damages and expenses, including any attorney’s fees, arising out to: ViSalus, 1607 East Big Beaver, Suite 110, Troy, Michigan 48083. of my actions or conduct in violation of this Agreement, Compensation Plan or any Policy or Procedure of VISALUS. I agree that in order to recoup any6. I agree that as a VISALUS Promoter, I shall place primary emphasis damages and expenses it has incurred due to such violation(s), VISALUS upon the sale of Products and Services to non-Promoter consumers as may offset any commissions or other payments due me. In the event a a condition of my receipt of commissions. Commissions I receive will dispute arises as to the respective rights, duties and obligations under this be based upon fulfilling certain terms of qualification as set forth by Agreement, Compensation Plan or the Policies and Procedures of VISALUS, the Marketing Program and Compensation Plans as may be amended it is agreed that such disputes shall be exclusively resolved in the Circuit from time to time. A three ($3.00) Dollar processing fee will apply to all Court for Oakland County, State of Michigan, or Federal Court located in payments. Detroit, Michigan. Michigan law shall apply to the resolution of all disputes.7. I agree to keep accurate records and to abide by all federal, state, and Louisiana residents may choose Louisiana law and jurisdiction. local laws and regulations governing the sale or solicitation of the products 20. I acknowledge that I have read and fully understand the VISALUS Policies and services marketed by VISALUS including, but not limited to, any and all and Procedures and Compensation Plan, which are incorporated herein permits and licenses required to perform under this Agreement. by reference and are binding upon me. In order to maintain a viable8. I understand that no attorney general or other regulatory authority ever marketing program and to comply with changes in federal, state or local reviews, endorses, or approves any product, subscription, compensation laws or economic conditions, VISALUS may revise its Compensation Plan program or company, and I will make no such claim to others. and Policies and Procedures from time to time. All changes thereto shall be9. I understand that a $25 Administration Fee will be charged annually to my effective upon verbal or written notice to me and become a binding part of credit card on file with ViSalus. This fee is for services, which include, but this Agreement. The home office prior to use or publication must approve are not limited to, downline reporting, customer tracking and accounting all advertisements using the Proprietary Marks of VISALUS. services. The Administration Fee will be charged in the month of my 21. I acknowledge that this Agreement, Compensation Plan and the Policies enrollment anniversary and if not paid will result in my Promotership and Procedures incorporated herein by reference, constitute the entire being placed on Financial Hold for up to 120 days. If the Administration Agreement between the parties and shall not be modified or amended Fee remains unpaid 120 days after it was due, my Promotership will be except in writing signed by VISALUS. This Agreement shall be binding upon terminated and I will forfeit any commissions that were held since the and inure to the benefit of heirs, successors, and permitted assigns of the time I was placed on Financial Hold. If my Promotership is terminated, I parties hereto. If any provision of the Agreement is determined by any understand that I must re-enroll as a brand new Promoter and will not be authority of competent jurisdiction to be invalid or unenforceable in part or placed back in my original spot if I wish to pursue the ViSalus opportunity. in whole for any reason whatsoever, the validity of the remaining provisions10. I agree that VISALUS shall not be liable under any circumstances for or portions thereof shall not be affected thereby. any damage or loss of any kind, including indirect, special, punitive, 22. I agree to abide by the terms of the noninterference and non-disclosure compensatory, or consequential damages, losses or profits which may policy of VISALUS. result from any cause, including but not limited to, breach of warranty, 23. During the term of this Agreement (and any renewals), I will not sell delay, act, error or omission of VISALUS, or in the event of discontinuation any other products for any entity competing with VISALUS. I agree that or modification of a product or service offered by VISALUS. I no longer promote any other organization that utilizes a multi-tiered11. VISALUS shall periodically make sales literature and/or promotional compensation plan. materials available. However, I am under no obligation to purchase any 24. During the term of this Agreement (and any renewals) and for one (1) year materials or literature at any time. Refunds shall not be allowed under any thereafter, I understand and agree that I will not contact, solicit, or recruit circumstances, including, but not limited to, termination of this Agreement, any VIP, whether active or inactive, into any organization that utilizes a obsolescence of such sales literature or promotional materials, or any other multi-tiered compensation plan. This includes indirect recruiting through reason. Except as specified in paragraph 26. Facebook or other social media. I acknowledge that my violation of this12. I agree that as a Promoter, this Agreement grants me the limited authority provision will result in immediate termination of my Promotership and to promote and sell the products VISALUS markets subject to the terms and payments of any kind. conditions established by VISALUS. 25. I understand that if for any reason a VIP violates any of the terms of the13. I will not make any false or misleading statements about VISALUS or Agreement and/or these Policies and Procedures, ViSalus reserves the its marketing program. I agree that I will operate in a lawful, ethical right to immediately deactivate or terminate the VIP’s position. Such action and moral manner and will not engage in or perform any misleading, by ViSalus will terminate any and all rights of the VIP and any further deceptive or unethical practices. In the event I violate any of these payments of any kind and is effective at the time of said violation. conditions, my position may be terminated without further payment or 26. ViSalus Executive and Business Opportunity Return Policy: An Independent compensation of any kind. Promoter who cancels their Promotership within 30 days of enrollment may14. I acknowledge that I am responsible for supervising and supporting return unused products from the Promoter Systems which are unopened Promoters I sponsor into the program and in my commissionable network. I and in resalable condition. A refund will be issued for the value of the agree to maintain monthly communication and support to those individuals Business Opportunity ($49) and the value of unused and saleable products in my commissionable network through written or verbal communication up to $450. If an Independent Promoter cancels their Promotership within and attendance at meetings. their first year but more than 30 days after their enrollment date, the same15. I acknowledge that VISALUS expressly reserves all proprietary rights to guidelines apply however returned, saleable products will result in a the company’s trademarks, tradenames, logos (“Proprietary Marks”) and product credit equal to the discounted value of those products (up to $450) copyrighted materials. I understand, acknowledge and agree that any rather than a refund and will be subject to a restocking fee. monies which I pay VISALUS are in consideration of my receiving a non- exclusive license, during the term of this Agreement to use the Proprietary Marks of VISALUS as stipulated in the Policies and Procedures and in Please initial here_________ to acknowledge that you have read and conjunction with the marketing program provided to me. I further agree agree to the above Terms of Agreement. Your application is not complete that I will not use VISALUS’s Proprietary Marks in any form whatsoever unless you initial this page and submit with your Independent Promoter except as permitted in writing by VISALUS or in advertising or promotion Application. materials provided, designed or published by VISALUS. I understand that I may not photocopy or duplicate any materials provided by or purchased 1607 E. Big Beaver Rd. Suite #110, Troy, MI 48083 • Customer Service 1.877.VISALUS • vi.com © 2012 ViSalus, Inc. All rights reserved. D1000US-25 2/2
  • 5. 1607 e Big Beaver rd Suite #110, troy, mI 48083 Product Order Form Customer Service 1.877.VISALUS Fax Form To: 877.547.1570 Balance Kit $49 Auto-Ship Price Shape Kit $ 99 Auto-Ship Price Core Kit $ 199 Auto-Ship Price Save $19 off retail prices Save $37 off retail prices Save $79 off retail prices 1 Pouch Vi-Shape® 2 Pouches Vi-Shape® 1 Vi-pak® (30 daily AM/PM packets) Nutritional Shake Mix Nutritional Shake Mix 1 Pouch Vi-Shape® 5 Packets Shape-Up™ 10 Packets Shape-Up™ Nutritional Shake Mix Health Flavor Mix-Ins Health Flavor Mix-Ins 5 Packets Shape-Up™ Health Flavor Mix Ins 2 Boxes ViSalus NEURO™: 1 each Add the full Vi-pak® to your Challenge Kit (Auto-Ship Only) Only $99 Raspberry Boost & Lemon Lift Transformation Kit $ 249 Fit Kit $ 299 Auto-Ship Price Auto-Ship Price Save $90 off retail prices Save $110 off retail prices 2 Pouches Vi-Shape® Nutritional Shake Mix 2 Pouches Vi-Shape® Nutritional Shake Mix 10 Packets Shape-Up™ Health Flavor Mix-Ins 5 Packets Shape-Up™ Health Flavor Mix-Ins 1 Bottle Vi-Slim® Metab-Awake! Tablets 2 Boxes ViSalus PRO™ Prolonged Energy Drink Mix 1 Box Vi-Trim® Clear Control Drink Mix 2 Boxes ViSalus GO™ Instant Energy Drink 1 Bottle Omega Vitals Supplement 30 ViSalus Nutra-Cookies™: 10 each flavor– 2 Boxes ViSalus NEURO™: 1 each Raspberry Boost & Lemon Lift Chocolate Chip, Oatmeal Raisin, and Peanut Butter Item No. ProDUCt DeSCrIPtIoN WHoLeSALe retAIL qty totAL AUto-SHIP K0020 Body by Vi Balance Kit ™ $49 $61 ▢ 5 ▢ 12TH ▢ 19TH TH K0021 Body by Vi Shape Kit ™ $99 $124 ▢ 5TH ▢ 12TH ▢ 19TH K0019 Body by Vi™ Core Kit $199 $249 ▢ 5TH ▢ 12TH ▢ 19TH K0015 Body by Vi™ Transformation Kit $249 $311 ▢ 5TH ▢ 12TH ▢ 19TH K0048 Body by Vi™ Fit Kit $299 $374 ▢ 5TH ▢ 12TH ▢ 19TH Add Vi-pak® to your Challenge Kit (Auto-Ship only) $99 n/a ▢ 5TH ▢ 12TH ▢ 19TH N1210 Vi-Shape® Nutritional Shake Mix (30 Serving Pouch) $45 $59 ▢ 5TH ▢ 12TH ▢ 19TH N1211 Vi-Shape® Nutritional Shake Mix (15 Individual Packets) $28 $36 ▢ 5TH ▢ 12TH ▢ 19TH N1227 Nutra-Cookie™ Chocolate Chip (14 Individually Wrapped Cookies) $34 $40 ▢ 5TH ▢ 12TH ▢ 19TH N1228 Nutra-Cookie™ Oatmeal Raisin (14 Individually Wrapped Cookies) $34 $40 ▢ 5TH ▢ 12TH ▢ 19TH N1229 Nutra-Cookie™ Peanut Butter (14 Individually Wrapped Cookies) $34 $40 ▢ 5TH ▢ 12TH ▢ 19TH K0029 Nutra-Cookie™ Chocolate Chip 4-Pack (4 boxes) $125 $150 ▢ 5TH ▢ 12TH ▢ 19TH K0030 Nutra-Cookie™ Oatmeal Raisin 4-Pack (4 boxes) $125 $150 ▢ 5TH ▢ 12TH ▢ 19TH K0028 Nutra-Cookie™ Variety 4-Pack (2 boxes each Chocolate Chip and Oatmeal Raisin) $125 $150 ▢ 5TH ▢ 12TH ▢ 19TH N1212 Vi-Slim® Metab-Awake! Tablets (30 Tablets per Bottle) $40 $50 ▢ 5TH ▢ 12TH ▢ 19TH N1213 Vi-Trim® Clear Control Drink Mix (30 Individual Packets) $40 $50 ▢ 5TH ▢ 12TH ▢ 19TH N1214 Shape-Up™ Health Flavor Mix-In Strawberry (15 Individual Packets) $10 $12.50 ▢ 5TH ▢ 12TH ▢ 19TH N1215 Shape-Up™ Health Flavor Mix-In Chocolate (15 Individual Packets) $10 $12.50 ▢ 5TH ▢ 12TH ▢ 19TH N1216 Shape-Up™ Health Flavor Mix-In Banana (15 Individual Packets) $12 $15 ▢ 5TH ▢ 12TH ▢ 19TH N1217 Shape-Up™ Health Flavor Mix-In Peach (15 Individual Packets) $12 $15 ▢ 5TH ▢ 12TH ▢ 19TH N1218 Shape-Up™ Health Flavor Mix-In Orange (15 Individual Packets) $12 $15 ▢ 5TH ▢ 12TH ▢ 19TH K0010 Health Flavor Mix-In Variety 5–Pack (1 box of each flavor) $50 $63 ▢ 5TH ▢ 12TH ▢ 19TH N1002 Vi-pak® (30 Daily AM/PM Packets) $125 $150 ▢ 5TH ▢ 12TH ▢ 19TH N1225 ViSalus Pro™ Prolonged Energy Drink Mix – Passionfruit (15 packets) $32 $40 ▢ 5TH ▢ 12TH ▢ 19TH N1226 ViSalus Go™ Instant Energy 2 oz. Shot – Grape (15 ready-to-drink bottles) $48 $60 ▢ 5TH ▢ 12TH ▢ 19TH N1070 ViSalus NEURO™ Raspberry Boost Drink Mix (15 Packets) $24 $30 ▢ 5TH ▢ 12TH ▢ 19TH N1071 ViSalus NEURO™ Lemon Lift Drink Mix (15 Packets) $24 $30 ▢ 5TH ▢ 12TH ▢ 19TH Side 1 Sub-TotalForm continues on reverse © 2012 ViSalus, Inc. All rights reserved. D1001US-21 1/2
  • 6. 1607 E Big Beaver Rd Suite #110, Troy, MI 48083 Product Order Form Customer Service 1.877.VISALUS Fax Form To: 877.547.1570 Item No. product description WHOLESALE RETAIL qty total auto-ship N1077 ViSalus NEURO Raspberry Boost Drink Mix (25 Serving Jar) ™ $38 $48 ▢ 5TH ▢ 12TH ▢ 19TH N1076 ViSalus NEURO Lemon Lift Drink Mix (25 Serving Jar) ™ $38 $48 ▢ 5TH ▢ 12TH ▢ 19TH N1221 Anti-Aging & Energy Supplement (30 Capsules per Bottle) $44 $55 ▢ 5TH ▢ 12TH ▢ 19TH N1222 Supercharged Antioxidant Supplement (30 Tablets per Bottle) $34 $42.50 ▢ 5TH ▢ 12TH ▢ 19TH N1223 Multi Mineral & Vitamin Supplement (60 Tablets per Bottle) $24 $30 ▢ 5TH ▢ 12TH ▢ 19TH N1224 Omega Vitals Supplement (60 Softgels per Bottle) $34 $42.50 ▢ 5TH ▢ 12TH ▢ 19TH N1050 Vimmunity $28 $35 ▢ 5TH ▢ 12TH ▢ 19TH Side 1 SHIPPING SCALE Check one date for each individual Total Order Total Shipping Order Total Shipping Order Total Shipping product you would like Auto- From To From To From To Date Ordered: / / Shipped to you each month. $0 $0.99 . . . . . . . . . . $0 $150.01 $300.00. . . . . . . . $14 $2490.00 $4989.99. . . . . . . $50 NOTE: Tax and Shipping & Handling will be added to total. $0.99 $50.00. . . . . . . . . $6 $300.01 $500.00. . . . . . . . $19 $4990.00 $9989.99. . . . . . . $80 $50.01 $150.00. . . . . . . . $10 $500.01 $2489.99. . . . . . . $25 $9990.00 ∞ . . . . . . . . . . . . $125 ViSalus Auto-Ship Advantage Program Retail Price: Price for customers who want the product one time. Choose the Auto-Ship Program to guarantee you never run out of product. Distributor Wholesale Price: Price for distributors and Auto-Ship Advantage Program customers. • Initial orders will be processed and shipped upon receipt. *Please note: it is against ViSalus policy to sell any ViSalus product below its wholesale price. • Auto-Ship orders will be processed & shipped starting next month on the selected date. See www.visalus.com for up-to-date product information and additional items. • Auto-Ship orders will be processed on the last business day before a weekend or holiday. • Changes to Auto-Ship orders must be received at least 5 days prior to Auto-Ship date. • Customers who select Auto-Ship are “Preferred” and can receive Wholesale pricing. Customer Shipping Information Customer Billing InformationLast Name:________________________ First Name:_______________________ Full Name on Credit Card:______________________________________________Shipping Address:___________________________________________________ Billing Address:____________________________________________________Apt/Suite:_______________________________________________________ Apt/Suite:_______________________________________________________City: ___________________________ State:_______ Zip:_______________ City: ___________________________ State:_______ Zip:_______________Daytime Phone #:___________________________________________________ Credit Card Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|E-mail Address:____________________________________________________ Expiration Date:_____________________ Security Code:_____________________▢ Yes, I would like to receive communications from ViSalus regarding special discounts Card Type: ▢ Visa ▢ MasterCard ▢ Discover ▢ American Express and promotions. Cardholder Signature:________________________________________________Fill in the Name and ID number of the ViSalus Customer or Promoter signing you up today: I authorize ViSalus Sciences to charge my account for the amount listed. I promise to pay such amount to andLast Name:________________________ First Name:_______________________ in agreement governing the use of such card. I understand that ViSalus Sciences will apply Taxes, Shipping and Handling charges to my order. If order is Autoship, I authorize ViSalus to ship these products monthly.ViSalus ID # or SSN:__________________________________________________ Cancellations must be submitted 5 days prior to the Auto-Ship date. Fax Order to 1.877.547.1570, call 1.877.VISALUS, or place order online at www.visalus.com © 2012 ViSalus, Inc. All rights reserved. D1001US-21 2/2