Printable Order Form
Please Print


Quantity________Product #_______________Product Name ______________________________________,

Quantity________Product #_______________Product Name ______________________________________,

Quantity________Product #_______________Product Name ______________________________________,

Quantity________Product #_______________Product Name ______________________________________,

Name ________________________________________ exactly as shown on credit card

Address_______________________________________________________

City _____________________ Zip Code________________ The zip code determines your state


UPS Shipping Information If different from billing information.

Name______________________________________

Address______________________________________________No PO Box # allowed

City _______________________

Zip Code_________________The zip code determines you state

Buy wholesale!
For or a one time fee of $10.00 become an Associate.

PLEASE CIRCLE ONE (Customer / Associate )

Social Security or Federal Tax ID number._______-______-________ Associates Only

Home Phone #_____-_____-_________

EMail Address_______________________@__________________________

Type of Card: ____________

Card Number: _______/_______/_______/_______

Card Expiration: ___/_____

Or make check payable to Jacque Dreher and mail to:

Jacque Dreher
Youngevity Associate
PO Box 687, Idaho Springs, Co. 80452

Shipping & Handling: 8% of subtotal or $6.50 whichever is greater
Sales Tax: ( if required by your state )

Free Shipping & Handling if you have your order AutoShipped each month
(On Credit Card orders only)
(NOTE:THERE WILL BE A SHIPPING CHARGE ON YOUR INITIAL ORDER.)
For AutoShip, type or print AutoShip Here: ___________________________