EmailMe Form - Customer Enrollment Form

Customer Enrollment Form
Instructions: Please enter your information. Answer all questions.

Personal Information

Name *

Prefix

First *

Last *

Suffix

Address *

Street Address *

Address Line 2

City *

State / Province / Region *

Postal / Zip Code *

Country *

Email

Phone Number *

###

####

Are you over 18 *

Yes

Enter Birthday *

YYYY

Preferred Customer or Direct Customer

You can enroll as either a Preferred Customer or a Direct Customer. Preferred Customers receive 30 – 40% off the regular price of Melaleuca products by purchasing at least 35 product points each month. Preferred Customers are also included in the marketing executive status and earns monthly payments when referring other customers. Direct Customers pay the regular price for Melaleuca products.

Preferred Customer

* 30 - 40% discount on all purchases
* Participate in the Loyalty Shopping Dollars Program

Direct Customer

* Products must be purchased at full price. No discounts.

Position Applied For *

Days Available for Marketing Executives *

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Any

Hours Available *

Any

Not required.

Comments or Requests *

After review of your application, you will receive a secured email with a summary of your application. Please follow instruction to review and submit your application.

Additional information will be required including a social security number to complete your Independent Marketing Agreement or add spouse to Customer Membership Agreement.

I certify that information contained in this application is true and complete.

Do you agree? *

Yes, I agree.

Initial *

Date *

YYYY

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