Autoship & Store Purchase Form

Store Transfer and Autoship Form

Name
N/A

Required First Name Required Last Name
Shipping Address
N/A

Required
Street Address
Address Line 2 Required City Required State/Region/Province Required
Postal / Zip Code

United States
Country
Email *
N/A
Your Personal Store (Required) *
N/A

Personal Store ($29.99 per month)
Select the Date to be charged for your personal store. *
N/A

MMMM-dd-yyyy

Personal Store Payments are mandatory to remain active. Your card will be charged on the same DAY of each month. (28th, 29th, or 30th days may vary)
(OPTIONAL) Which digital product are you selecting for monthly payment?
N/A

Digital Combo Services- Healthcare Plus & ID Protection ($79.99 per month "PERSONAL STORE COST WILL BE WAIVED")
Healthcare Plus ($50.00 per month)
Allstate Identity Protection ($29.99 per month)
Select the Date to be charged for your digital product.
N/A

MMMM-dd-yyyy

Your card will be charged on the same DAY of each month. (28th, 29th, or 30th days may vary)
(Optional) 1st Supplement Selection
N/A

-Select-

You will be able to change your autoship and add new products once your new website is active. Ethiopian and Colombian coffee will be temporarily unavailable
Select the Date to be charged for your 1st supplement.
N/A

MMMM-dd-yyyy

Your card will be charged on the same DAY of each month. (28th, 29th, or 30th days may vary)
(Optional) 2nd Supplement Selection
N/A

-Select-

You will be able to change your autoship and add new products once your new website is active. Ethiopian and Colombian coffee will be temporarily unavailable
Select the Date to be charged for your 2nd supplement.
N/A

MMMM-dd-yyyy

Your card will be charged on the same DAY of each month. (28th, 29th, or 30th days may vary)
(Optional) 3rd Supplement Selection
N/A

-Select-

You will be able to change your autoship and add new products once your new website is active. Ethiopian and Colombian coffee will be temporarily unavailable
Select the Date to be charged for your 3rd supplement.
N/A

MMMM-dd-yyyy

Your card will be charged on the same DAY of each month. (28th, 29th, or 30th days may vary)
Name on Credit Card
N/A

Required First Name Required Last Name
Credit or Debit Card Type *
N/A

-Select-
Card Number (SECURED) *
N/A
Expiration Date *
N/A

mmyy
CID *
N/A
Billing Address
N/A

Required
Street Address
Address Line 2 Required City Required State/Region/Province Required
Postal / Zip Code

Required
-Select-
Country
PLEASE NOTE *
N/A

THE PURPOSE OF THIS FORM
The purpose of this form is to transfer your account data from the previous rep system on the Hotshot Mall, to the current and updated rep system. You will not lose any data. This is just a transfer. We will require your credit card because you are still required to maintain your personal site and store with the $29.99 per month. We will set up the recurring charge on the exact same day as it is now. Once you have your login details which will be emailed, you will be able to do various updates in your back office. Once transferred, we will no longer have access to your credit card information so any changes will have to come from you in your back office.

I understand the purpose of this form
Signature (Sign with finger or mouse) *
N/A

E-Signature Field
Clear

Store Transfer and Autoship Form

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