New Unicity Form
New Unicity Form
New Unicity Form
Distributorship Agreement
Name (First)
Applicant Information
Name (Last) Full name as it appears on bank account Co-Applicant Name (Last) (if applicable) Street Address (Current Mailing Address) City Shipping Address E-mail Address State STD Code PIN Code Mobile Phone Number Work Phone Number Co-Applicant Name (First) Pan Birth Date (DD/MM/YYYY) Birth Date (DD/MM/YYYY) STD Code
MF Gender MF Gender
The Enroller is the Distributor who is recruiting an individual to become a new Distributor with Unicity. The Enroller may also be the Sponsor.
Enroller Name STD Code Daytime Phone Number
Sponsor Information
Distributor ID Number
Expiration (MM/YY)
CVC
Account Name: Unicity Health Private Limited Account Number: 02392560001958 Cardholders Name (Last, First, Middle Initial) IFSC Number: HDFC0000239 Swift Code: HDFCINBBXXX Bank Name: HDFC Bank Branch Address: 239-Powai - Hiranandani, Prudential Building, Ground Floor, Hiranandi Business Park, Powai, Mumbai - 400076, Maharashtra
Order Information
Item Number Product Description Quantity PV Unit Price Total PV Extended Price
Bank Information
Full Name of Bank Full Address of Bank Branch Full name of account holders as stated on bank account Bank Account Number Pin Code Bank Swift Code Full Name of Bank Branch Bank Branch Indian Financial System Code (IFSC)
By signing and submitting this form along with a copy of my PAN card and proof of my address, I acknowledge that I am applying to become a Unicity Distributor. I understand a product purchase must be submitted within 60 days of enrollment to activate my Distributorship. Failure to activate the account will result in termination of the Distributorship. I consent to Unicity contacting me at the telephone numbers, fax number, and/or e-mail address listed on my application or as updated. I certify that I have read and agree to the Terms and Conditions on the reverse side of this form. I further certify that I have received, have read, understand, and agree to the Unicity Award and the Unicity Policies & Procedures, which are incorporated herin and made part of this Agreement. This form has no cash value.
Date (DD/MM/YYYY)
Co-Applicant Signature
Date (DD/MM/YYYY)
ID 1012
2012 Unicity Health Private Limited 401-404 Dynasty Business Park BWing, Level4 Kanakia Spaces, Andheri (East), Mumbai400 069 Distributor and Applicant may photocopy this form or download it from www.unicity.net/india