Account Info
First Order
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Account Information

Contact Information

  • First Name First Name is required
    Last Name Last name is required
  • Email Valid email address is required
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    Phone Phone is required
  • Choose Password Password must be at least 4 characters in length.
    Confirm Password Make sure the passwords match
  • Social Security Number
    Social Security Number is required
    Birth Date
    Birthdate is required
    Language Language is required

Enroller/Sponsor Information

  • Enroller ID Number Enroller is required

Billing Address

  • Address is required
    Billing Address Line 2 is required.
  • City is required
    Billing State is required
  • Zip code is required
    Country is required

Shipping Address

  • Name Name is required
  • Address Address is required
    Address Line 2 Shipping Address Line 2 is required
  • City City is required
    State State is required
  • Zip Code Zip code is required
    Country Country is required

Agreement

  • By checking this box, I acknowledge that I have read 4Life's Terms and Conditions. I further acknowledge that I have read and understand 4Life's Consent to Electronic Record.
    Electronic consent is required
  • By checking this box, I acknowledge that I have read 4Life's Privacy Policy. I understand and agree to be bound by the terms of 4Life's Policies & Procedures.
    Policies and Procedures are required
  • The following declaration is required in order to fulfill 4Life’s obligations under U.S. IRS Form W-8BEN:

    Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that:

    1. I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates,

    2. The beneficial owner is not a U.S. person,

    3. The income to which this form relates is (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is not subject to tax under an income tax treaty, or (c) the partner’s share of a partnership’s effectively connected income, and

    4. For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.

    Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner.


    W8Ben required
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