1.
Independent Consultant Application
1.Please print clearly in blue or black ink. 2. Fill out all required fields denoted by an asterisk (*). Your application cannot be processed without this information. 3. Complete the
Independent Consultant Order Form, which is required with your application, to purchase Business Bag.
__Checkhere______ifyou havea Bloomfield Bath Account andwishtoretain thisaccount information as your Bloomfield Bath Business.
nMr. n Mrs. n Ms. n Miss
First Name* Last Name* MiddleName
Address*
City* State * Zip Code*
nMale nFemale n
ForIndividual/SoleProprietorsonly:
ProvideSocial Security Number* __ __ __ - __ __ - __ __ __ __
OR
For Businesses only: Employer ID Number* __ __ - __ __ __ __ __ __ __ __ **W9 required to be filed for all Independent Consultants
Email* Birth Date* / / Mustbe18+yearsofagetoapply
Bus. Phone ( ) Home Phone* ( )
Fax ( ) Cell Phone ( )
Sponsor’s Consultant ID* Sponsor’s Name*
Applicant’sSignature*
Sponsor’s Signature*
Date / /
Date / /
Mail completed application to:
Bloomfield
Bath
P.O.
Box
8179,
Surprise
AZ.
85374
Toll
Free:
1.844.44.BLOOM
Text:
480.845.0144
Fax:
1.877.368.5254
Email:
consultant@bloomfieldbath.com
Koketta Knowles