1. Member Application & Agreement
To apply, you may complete an online application at www.javita.com or you may fax this completed form. If you apply by phone you must send the
application to us within 10 days or the agreement will be void. 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
Street Address (Current Mailing Address) City
Enrolling Member’s # or Federal Tax ID # Name (Last, First, Middle Initial)
Sponsoring Member’s # or Federal Tax ID # Name (Last, First, Middle Initial)
I understand the only financial requirement to become a Javita Member is a $49.95 application fee (plus any applicable tax) which includes a kit containing sales and demonstration materials and company
information produced by Javita Inc. I understand this kit does not contain commissionable products and any products purchased in connection with becoming a Member are optional. I have read and agreed to
the Policies & Procedures (online), and am familiar with the Javita exchange policy found in the Policies & Procedures, and agree with the terms and conditions, which by reference are fully incorporated into
this agreement. In addition, a yearly renewal fee of $14.95 is required to continue as a Javita Member.
A PARTICIPANT IN THE JAVITA INTERNATIONAL LTD. COMPENSATION PLAN HAS THE RIGHT TO CANCEL AT ANY TIME, FOR ANY REASON.
CANCELLATION MUST BE SUBMITTED IN WRITING TO JAVITA AT ITS PRINCIPAL PLACE OF BUSINESS.
(faxed copies may be deemed as originals)
Item # 11001 0512
(please PRINT all information clearly)
Sole proprietorship Corporation Partnership
Social Security # (or Federal Tax ID# for Business Entity only) Birth Date (MM/DD/YY)
Applicant Signature Today’s Date (MM/DD/YY)
The Enroller is the Member who is recruiting an individual to be a Member with Javita. The Enroller may also be the Sponsor. The Sponsor is the immediate
upline of the newly enrolled Member. If the Sponsor is the same as the Enroller, leave these fields blank.
Cardholder’s Name (Last, First, Middle Initial) Expiration Date (MM/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. Select from the options below if you wish to be part of Javita’s AutoShip Program:
Credit Card Security Code (3 or 4 digits) Authorization Signature
o 4 boxes (96 sticks) coffee $120 (100 PV) $20 savings on AutoShip
o Other: number of boxes _____ x $35 = __________
o 2 boxes (48 sticks) coffee $70 (50 PV)
AutoShip/Program
Drop5 Join Packs
*If applying under a business name, additional information is required. Contact Javita Member Services at 1-855-JAVITA-1.
Name (Last, First, Middle Initial) or Business Name* Area Code Daytime Phone Number
Co-Applicant/Spouse or Business Contact (if applicable) Mobile Number
State Country Zip Code Email
❍ Mastercard®
❍ Visa®
❍ Discover®
❍ American Express®
o Business Elite Pack ..................... $999 (900 PV)
Javita energy + mind coffee (32 boxes)
Javita-Branded Coffee Tumbler
Javita Sample Sleeves (100 pk)
Javita Member Kit
By joining with this pack, you are eligible to participate in our STAR
Bonus and Car Bonus Programs, have the Rank Advancement
Bonus qualifications waived and enjoy 5-level FastStart Bonus.
o Business Pack ........................... $499 (400 PV)
Javita energy + mind coffee (14 boxes)
Javita-Branded Coffee Tumbler
Javita Sample Sleeves (100 pk)
Javita Member Kit
By joining with this pack, you are eligible to participate in our STAR
Bonus and Car Bonus Programs, have the Rank Advancement
Bonus qualifications waived and enjoy 5-level FastStart Bonus.
o Starter Pack ....................... $99 (50 PV)
Javita energy + mind coffee (2 boxes)
Javita-Branded Coffee Tumbler
Javita Member Kit
o Member Kit only ........................ $49.95