This document appears to be a membership application form for AGEL. It requests information such as the applicant's name, date of birth, contact information, sponsor details, and payment method. The form offers various product packages that can be purchased as either a one-time retail purchase or ongoing monthly auto-ship. It collects banking information and provides spaces for an electronic signature and temporary password.

1. gawevrianebis blanki
AGEL Membership Information Form
piradi informacia (Applicant Information)
dro (Time) ------------------------------------ TariRi (Date)
-----------------------------------
gvari, saxeli (Name)­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­
dabadebis weli (Date Of Birth) ------/------/------
piradobis mowmoba-------------------------------------
telefoni (Phone) mob ------------------------- sax ------------------------- sam -------------------­­­­­­­
faqsi (Fax) ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­
el.fosta (E­mail)­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­
misamarTi (Mailing
Address)-----------------------------------------------------------------------
--------------
sponsoris informacia (Sponsor / Placement Information)
gvari,saxeli (Sponsor Name)­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­
telefoni (Phone) mob ------------------------- sax ------------------------- sam ­­­­­­­­­­­­­­­­­­­­­­­
sponsoris piradi nomeri (Id No.)­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­
gawevrianebis meTodi
Retailer
285$ 4 yuTi პროდუქცია ან 1 yuTi kosmetika AGELESS
Monthly Autoship - ყოველთვიური გზავნილი
gadasaxadis TariRi: 1 ricxvi / 5 ricxvi / 10ricxvi
nawarmi romelic minda miviRo pirveli SekveTiT (aRniSneT yuTebis raodenoba)
­­­­OHM/ ­­­­MIN/ ­­­­FIT/ ­­­­EXO/ ­­­­UMI/
­­­­FLX/ ­­­­HRT/
nawarmi romelic minda miviRo meore Tvidan (aRniSneT yuTebis raodenoba)
­­­­OHM/ ­­­­MIN/ ­­­­FIT/ ­­­­EXO/ ­­­­UMI/ ­­­­FLX/ ­­­­HRT/
gadaxdis gza
gadaricxva - rekviziti
SWIFT CODE#: LUMILITXXX
BRANCH: //IL010968
BANK LEUMI
ISRAEL
FOR ACC.#: 544500/83

2. FAVOUR OF: AGEL ISRAEL L.T.D
IBAN CODE:
IL 77 0109 6800 0005 4450 083
(saqonlis miReba angariSis ganaRdebis Semdeg )
gasaRebi(Temp.Password) ---------------------------- arCeuli saxeli (ID No.)
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xelmowera (Signature)----------------------------------------