SPONSOR INFORMATION

*****IMPORTANT *****IMPORTANT *****

If your Sponsor ID number is not displayed below, please call the office at 904-269-3240 Mon.-Fri., 8am to 5:30pm for assistance. If you want to sign up as a Preferred Customer and do not have a sponsor, the ID number displayed should be 2. Re-Vita will sign you up automatically under someone in your area. When you click the submit button below, you MUST make sure that you have the correct sponsor. If you do not confirm this, it can result in you not being placed under the desired sponsor.

Only one membership is permitted per person. Each membership requires a unique SSN or TaxID, which cannot be changed once it is entered.

Sponsors ID Number *:
Barnet G. Meltzer MD

 APPLICANT INFORMATION

 Primary Applicant
ID# (SSN, EIN, TIN or Other)*:
First Name*:
Last Name*:
Birth Date:
(MM/DD/YYYY)
 
  Spouse or Company
First Name:
Last Name:
 
 Billing Address
Address*:
City*:
State*:
Country*: United States
Zip or Postal Code*:

Note: This billing address MUST match the address on your credit card statement or on the checking account that is used for payment.
 
 Shipping Address (leave blank if same as above)
Address:
City:
State*:
Country: United States
Zip or Postal Code:
 
 Contact Information
Primary Phone*:
Cell Phone:
Other :
Fax:
Current E-mail*:
Check this box to receive information via e-mail from Re-Vita.
Check this box to receive information via e-mail from your upline sponsor(s).
 
 Additional Information
Select Your Time Zone*:

Please enter and verify a password that you will use to login to your VirtualOffice site. This password must consist of only letters or numbers and must be between 4 and 15 characters in length.
Password*:
Confirm Password*:

Your VirtualOffice tools will include a Re-Vita e-mail account. Please enter the name you would like to use. Use only letters, numbers, and underscores.
The e-mail address you choose will also be used for your business site name.
New Email Account Name: @re-vita.net

TERMS AND CONDITIONS

I agree to the policies, procedures, terms and conditions set forth in the Re-Vita Associate Agreement, and I verify that I am 18 years of age or older.


VIRTUAL OFFICE PACKAGE AND USAGE AGREEMENT

The Essentials Package provides you with an organizational management tool designed to support your business' operation. With NetTrax, you will enjoy real time access to downline-genealogy reporting, your upline listing, product ordering, and package tracking. You also recieve a personal Business Site and a personal email address. Other tools include the ability to listen to WebMeetings and the Televox Messaging web interface.

I agree to abide by the VirtualOffice Agreement as outlined above.


 ORDER

As an Associate of Re-Vita, please select one of the following options for your startup kit:

If you reside in North Dakota the purchase of the Associate Kit is optional.

Re-Vita Associate Kit - $49.95
Includes DVDs, CDs, Product Samples (included free of cost). Instructional, Marketing and Sales Materials (sold at company cost)
I live in North Dakota and do not wish to purchase an Associate Kit

At this time you have the option to purchase additional items by selecting one or more of the items listed below. Enter the quantity of each item you would like to purchase in the space provided.

Select Quantity Item Code: Product Unit Price
LH111: Re-Vita LiquaHealth - 60 Packets - Very Berry 64.00
LH112: Re-Vita LiquaHealth - 60 Packets - Lemon-Lime 64.00
LH113: Re-Vita LiquaHealth - 60 Packets - Chocolate 64.00
LH114: Re-Vita LiquaHealth - 60 Packets - Butternut 64.00
LH115: Re-Vita LiquaHealth - 60 Packets - Vanilla 64.00
LH060: Assorted Re-Vita LiquaHealth Flavors 60 Packets 64.00
LHJ1: LiquaHealth Very Berry 17oz. Jug 32.00
LHJ2: LiquaHealth Lemon-Lime 17oz. Jug 32.00
LS111: Re-Vita LiquaSpirulina 60 Packets - Very Berry 56.00
LS113: Re-Vita LiquaSpirulina 60 Packets - Great-Grape 56.00
LS112: Re-Vita LiquaSpirulina 60 Packets - Lemon-Lime 56.00
LS114: Re-Vita LiquaSpirulina - 60 Packets - Butternut 56.00
3700: Sm. Pump 1.00
LS060: Assorted Re-Vita LiquaSpirulina Flavors 60 Packets 56.00
LSJ1: LiquaSpirulina - Very Berry 17 oz. Jug 28.00
LSJ3: LiquaSpirulina Great-Grape 17oz. Jug 28.00

 AUTOSHIP

You may create a Monthly AutoShip Order by entering a quantity for one or more of the items below. Your first AutoShip Order will be processed on the date you choose below, beginning next month. Your regular ship date will be the same day of the month every month.

To start your Autoship this month, please call our office at 904-269-3240 or e-mail us at info@re-vita.com

To ensure your monthly qualifications, a minimum product order of $100.00 per month is required. AutoShips of $100 or more in product qualify for FREE SHIPPING. Alaska, Hawaii and Puerto Rico are standard 2-Day Air and qualify for free shipping.


Select Quantity Item Code: Product Unit Price
LSJ1: LiquaSpirulina - Very Berry 17 oz. Jug 28.00
LSJ3: LiquaSpirulina Great-Grape 17oz. Jug 28.00
LH111: Re-Vita LiquaHealth - 60 Packets - Very Berry 64.00
LH113: Re-Vita LiquaHealth - 60 Packets - Chocolate 64.00
LH114: Re-Vita LiquaHealth - 60 Packets - Butternut 64.00
LH115: Re-Vita LiquaHealth - 60 Packets - Vanilla 64.00
LH112: Re-Vita LiquaHealth - 60 Packets - Lemon-Lime 64.00
LHJ1: LiquaHealth Very Berry 17oz. Jug 32.00
LHJ2: LiquaHealth Lemon-Lime 17oz. Jug 32.00
LS111: Re-Vita LiquaSpirulina 60 Packets - Very Berry 56.00
LS112: Re-Vita LiquaSpirulina 60 Packets - Lemon-Lime 56.00
LS113: Re-Vita LiquaSpirulina 60 Packets - Great-Grape 56.00
1710: Re-Vita's All Natural Fiber 15.00

Ship Day: