2205 York Rd Suite 14

Timonium, MD 21093
Support@MyDailyChoice.com

AFFILIATE APPLICATION FORM

Affiliate Application and Agreement

APPLICANT INFORMATION
First Name

Enroller ID#

Last Name

Address
City

State/ Provence

Country

Phone

Zip Code

Email

Login Setup for MyDailyChoice Website

Password

Username

ORDER INFORMATION

Monthly Autoship
Yes No

First Month Order:

Autoship Order:

Builder Pack - $69 - (50PV)

Builder Pack - $69 - (50PV)

Director Pack - $149 - (100PV)

Director Pack - $149 - (100PV)

Executive Pack - $299 - (200PV)

Executive Pack - $299 - (200PV)

*100 PV Qualifies You For The Whole Compensation Plan

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PAYMENT INFORMATION

Name on Credit Card:

Credit Card Number:

Cash Check Credit Card

First Name

Last Name

Middle Initial

Exp. Date: ( Month / Year)

(Enter 16 Digits)

3 Digit Security Code

For Cash Payments:

For Check:

Amount of Cash Enclosed

Make Check Payable to:

MyDailyChoice, Inc.

I hereby declare that I have read the terms of this agreement on the bottom of this Application Form and that I fully understand and
agree to abide by all terms herein, including but not limited to the policies and procedures and referral bonus plan located at
mydailychoice.com which are incorporated herein.

Signature

Date

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