Change Form

US and Canada

Date: ___________________________

PH.
FAX

Asian Market
All other markets

VERY IMPORTANT: Please check if this change affects your Autoship Order

1-800-577-0777
1-888-314-9827

PH.
FAX
PH.
FAX

65-6396-3789
65-6396-3787
480-927-8933
480-927-8939

____________________________________________________________________________________________________________________________________________
First Name

Last Name

Middle Initial

VID# ________________________________________________

INFORMATION TO BE CHANGED

(PLEASE CHECK AS MANY CATEGORIES AS APPLY)

Other (Please explain)

Name (legal name change, i.e., from maiden to married, etc.)
___________________________________________________________
Mailing Address (correspondence, checks, etc.)
Shipping Address (product shipments)

___________________________________________________________
___________________________________________________________

Telephone Number

___________________________________________________________

Facsimile Number

___________________________________________________________

CONTACT INFORMATION - SHOULD BE CHANGED TO

____________________________________________________________________________________________________________________________________________
First Name

Last Name

Middle Initial

VID# ________________________________________________
Address

__________________________________________________________________________________________________________________________

City /Locality

______________________State/Province/County ___________________________Zip/Postal Code_____________________Country___________

Shipping Address ____________________________________________________________________________________________________________________

City /Locality

______________________State/Province/County ___________________________Zip/Postal Code_____________________Country___________

Day Telephone
Fax

______________________________________ Evening Telephone ______________________________________________________________

________________________________________________________ Email

______________________________________________________________

SIGNATURE
Signature

VNC 2005

________________________________________________________

Date

__________________________________________________________

DID YOU REMEMBER TO SIGN AND DATE THIS FORM?

Vemma (07/11/05)