The document appears to be an auto-ship agreement and order form for a company called Javita. It provides information on setting up automatic monthly shipments of products ordered from Javita. It outlines the terms and conditions of the auto-ship program, including that orders will be shipped within two days of payment, shipping and handling fees, how to revise or cancel an auto-ship agreement, and return policies requiring a return merchandise authorization number. Customers agree to let Javita automatically charge their payment method and ship orders each month according to the details provided in the agreement.

1. Member / Customer Information
Referred By
Member # or Federal Tax ID # Name (Last, First, Middle Initial)
Area Code Daytime Phone Number E-mail Address
Applicant Signature Today’s Date (MM/DD/YY)
Order Information
Street Address (Current Mailing Address) City
Item # 11005 0611All faxed copies may be deemed as originals.
Payment Information
❍ Mastercard® ❍ Visa® ❍ Discover®
❍ American Express®
Credit Card Security Code (3 or 4 digits) Authorization Signature
Item # Description Price Qty Total Cost
* Total does not include applicable tax or shipping and handling.
Total *
AutoShip Program When selecting your product or pack, please refer to the product pricing online at www.javita.com.
Be sure to check "New AutoShip" if you'd like to make this a recurring monthly order.
AutoShip Agreement/Order Form
To set-up an AutoShip Order or submit an order, fill out the form below and fax to our office.
Send to: Javita International Ltd. at 7835 NW Beacon Square Blvd, Boca Raton, FL 33487.
Phone: 1-855-JAVITA-1 (1-855-528-4821) • Fax: 1-561-258-2341
Name (Last, First, Middle Initial) or Business Name Area Code Daytime Phone Number
Cardholder’s Name (Last, First, Middle Initial) Expiration Date (MM/YY)
State Zip Code E-mail Address Birth Date (MM/DD/YY)
This convenient program allows you to receive an automatically generated order each month from Javita. Cancellation of an AutoShip Order must be
done through Javita Member Services at least five business days prior to your scheduled ship date. By selecting AutoShip you authorize the company to
automatically ship your monthly order and collect the appropriate funds each month. Please supply ALL required information. Orders are subject to the local
sales tax of your region and will be added to your order total. Shipping & handling charges will also be added.AutoShip orders are billed each month coinciding
with your monthly order date.
Note: Your first order will be processed upon approval of this application, and subsequent orders will fall into the regular AutoShip billing & shipping
schedule beginning the following month.
New AutoShip
Change my AutoShip
This is NOT an AutoShip
Please check which one of the following apply:

2. JAVITA™
AUTOSHIP AGREEMENT
TERMS AND CONDITIONS. PLEASE READ THOROUGHLY. As a participant in the Javita AutoShip Program, I authorize Javita
Inc. ("Javita") to ship my order to me monthly after processing the payment method that I have indicated. Javita is under no
obligation to ship any products until full payment has been received. Shipment will take place approximately two days from
payment confirmation.
1. AUTOSHIP: All new AutoShip Agreements received will generate an order to be shipped within two days of receipt.
Each month thereafter, your AutoShip order will be sent on or about the same time each month. Orders received between
the 16th and end of month will be sent on or about the 15th of each month.
2. SHIPPING AND HANDLING: All AutoShip orders are shipped via ground shipping. Shipping and handling charges
applied to each AutoShip order are as follows: 5.75% of the order subtotal with a minimum of $7.50.
3. REVISION: You may revise your AutoShip Agreement monthly. To do so, submit a new AutoShip Agreement / Order Form
and check the box labeled Change my AutoShip or modify your agreement online by visiting www.javita.com. Javita Member
Services must have revisions no later than 5 business days prior to your next AutoShip shipment date. If the revision is received
less than 5 business days prior to shipment, there will be no guarantee that the revision will be effective for that shipment. The
revised application will be in effect for the next shipment date.
4. CANCELLATION: If a Member decides to cancel their AutoShip, a signed notification must be submitted to Javita
Member Services. Member Services must have cancellation notice no later than 5 business days prior to your next
AutoShip shipment date. If the cancellation is received less than 5 business days prior to shipment, there will be no
guarantee that the order will not ship.
5. RETURNS: Prior to any product being returned to Javita, a Return Merchandise Authorization (RMA) Number must be
issued. Please contact Javita Member Services to receive an RMA by calling 855-JAVITA-1 (1-855-528-4821).