Page 1 - 獨立經銷商申請同意書

電話 (Phone) (02) 8712 5598 獨立經銷商申請同意書
傳真 (Fax) (02) 8712 8189
INDEPENDENT DISTRIBUTOR
APPLICATION AND AGREEMENT

付入會費經銷商姓名: 付入會費經銷商會員號碼:

Name of Distributor Paying for Application Paying Distributor Market Taiwan ID No.

獨立經銷商資料 Independent Distributor Information
如果您已婚，必須填寫配偶的資料。夫婦二人被視為一個經銷商資格。If you are married you must include your spouse’s information on this form. Married individuals are treated as a single Distributorship.

請在適用的空格打勾。Tick all that apply. 個人經銷商 Individual 已婚經銷商 Married Distributor 公司戶經銷商 Entity Distributor

(請附上有關證明文件 Proof documents required if Business Organization is selected)

經銷商台灣國民身分證字號 Primary Distributor Taiwan Citizen Tax ID No. 經銷商的美安台灣會員號碼（如適用）Market Taiwan Distributor ID No., 優惠顧客號碼（如適用）Preferred Customer ID No.

或台灣長期居住者之稅籍編號（如非台灣公民） Taiwan Permanent Resident Tax ID No. (if not Taiwan Citizen) 申請人若為台灣公民，必須隨附國民身分證影本；若為長期居住者，必須提供長期居住者許可證影本、護照影本、
法律證明長期居住者文件影本。 All Applicants must submit a copy of their Taiwan Citizen ID card with the application.If Permanent
Resident a copy of Permanent Resident Picture ID, copy of original passport and copy of legal document for Permanent Resident (if any)
with the application.

個人經銷商的中文姓名 Chinese Name of Primary Distributor 個人經銷商的英文姓名（如適用） English Name of Primary Distributor, if Applicable

姓 Last Name 名 First Name 姓 Last Name 名 First Name

經銷商出生日期 Primary Distributor’s Date of Birth 公司戶經銷商的公司中文名稱（如適用）* Chinese Name of Entity Distributor Company, if applicable*
年Year/ 月Month/ 日Day/
男性 Male
女性 Female

公司戶經銷商的公司英文名稱（如適用）* English Name of Entity Distributor Company, if applicable* 公司的統一編號（如適用）* Business Organization Registration No., if applicable*

*若 以公司戶登記，您必須提供主管單位核准公司登記函或商業登記函影本、公司存摺影本、股東名冊及公司負責人身分證影本。*If using business entity you must provide a copy of Company Registration Certificate or the Business Registration Certificate,

a copy of the company’s bankbook, a complete list of principals and a copy of the Taiwan Citizen Tax ID of the responsible person.

住宅電話 公司電話 傳真 手機

Home Phone Business Phone Fax Mobile Phone

電子郵件地址 Email Address

（如適用）配偶的身分證字號 Spouse Taiwan Tax ID No. (if applicable)

配偶的中文姓名 Chinese Name of Spouse 名 First Name 配偶的英文姓名，如適用 English Name of Spouse 名 First Name
姓 Last Name 姓 Last Name

經銷商的戶籍地址（需與身分證上登記的地址相同） Primary Distributor’s Government Registered Address (as listed on Taiwan ID card)

郵遞區號 Postal Code 市/縣 City/County

市區／鄉鎮和街道地址 District and Street Address, Apt./Suite
經銷商收貨地址 Primary Distributor’s Shipping Address

郵遞區號 Postal Code 市/縣 City/County

市區／鄉鎮和街道地址 District and Street Address, Apt./Suite
推薦人資料（介紹您加入美安事業的經銷商） Sponsor Information (The distributor who sponsored you into the business) 推薦人經銷商會員號碼或身分證字號 Sponsor’s Distributor ID or Taiwan ID No.
推薦人姓名或公司名稱 Name of Sponsor

連線位置資料 Placement Information 連接經銷商的會員號碼或身分證字號 Link-to Dist., Dist. ID No. or Taiwan ID No. 分中心號碼 BDC Ext. No. 勾選一項 Tick One
連接經銷商姓名或公司名稱 Link-to Distributor or Business Organization

左邊 Left 右邊 Right

加入類別（請在適用的空格打勾。）Entry Classification (Tick One) 經 銷商，遲交年度續約表（交入會費）遲交續約表的經銷商（必須繳付現行的續約會
費）。請繳交適當的會費。Distributor, Late Renewal (Current subscription fee required). Please send the appropriate payment.
零售商（無需繳交續約費）
如果使用存檔的信用卡，請提供如下資訊：If using Credit Card on file please provide as follows:
Sales Representative (No fee required)
信用卡最後四位數字：___ ___ ___ ___ 有效期限至（月月/年年）：_____/_____
零 售商遲交年度續約表（無需繳交續約費）
Last four digits Exp. Date(mm/yy)
Sales Representative Late Renewal (No fee required)

經 銷商，主管級入會超連鎖®店主（主管級入會），申請時交入會費

Distributor, Master UnFranchise® Owner (Supervisory entry), (Current subscription fee required)

零 售商轉為經銷商（交入會費）

Converting Sales Representative to Distributor (Current subscription fee required)

匯入款銀行資訊 BANK ACCOUNT INFORMATION 爲了保證佣金順利發放，
本人同意美安台灣公司應將本人的佣金及獎金直接匯入以下指定之本人或配偶的帳戶中，以下本人簽名為證。 建議您向公司遞交銀行存
摺/月結單影本，以便輸入
As evidenced by my signature below, I agree that Market Taiwan should directly deposit my commission and bonus to the designated account below. 帳號資料。

銀行名稱 Name of Bank:_______________________________________________________________________ 分行名稱 Branch Name:______________________________ To ensure proper transfer of commissions, it
is recommended you send in a copy of your
帳戶持有人的姓名 :Account Holder’s Name 姓 Last Name：______________________________________________ 名 First Name:_____________________________________ passbook/statement for proper account entry.

銀行代號 Bank Code 通匯代號 Branch Number 帳號 Acct. No.

本人同意上述資訊，並確認本人已經閲讀、瞭解並同意此申請同意書背面所列條款，且有本人簽名為證。 日期: __________________________________

(I agree to the above indicated information and I ACKNOWLEDGE THAT I READ, UNDERSTAND AND AGREE TO THE TERMS SET FORTH ON THE BACK OF THIS AGREEMENT, AS EVIDENCED BY MY SIGNATURE BELOW.) Date

申請人經銷商簽名 ________________________________________________________________________________________________________ 日期: __________________________________

Primary Distributor’s Signature Date

經銷商配偶簽名（如適用） __________________________________________________________________________________________________ 日期: __________________________________

Distributor’s Spouse Signature, if applicable Date

推薦人簽名 ______________________________________________________________________________________________________________

Approved by Sponsor, Sponsor’s Signature

所有申請人必須簽署此申請同意書。若申請人為法人公司﹐則由負責經銷商簽署申請同意書。如有應付款項，請連同此表一併交給美安台灣公司。

All applicants must sign this agreement. If the applicant is a Company, the Primary Distributor must sign the application. ENCLOSE PAYMENT PAYABLE TO MARKET TAIWAN IF APPLICABLE.

將正本（第一聯）和第二聯連同入會費寄至： 請閲讀此申請同意書背頁的條款與守則。 僅供內部使用 INTERNAL USE ONLY
美商美安美台股份有限公司台灣分公司,10499台北郵政第34-339號信箱 承辦人姓名簡寫 Processor Initials: ______________
Mail original copy of application with subscription fee to: Please refer to the Terms and Conditions on the reverse 查核員姓名簡寫 Quality Monitor Initials: ___________
Market Taiwan, Inc., PO Box 34-339, Taipei, Taipei City 10499, Taiwan side of this page.

代號 Code: T103 正本 Original: 美安台灣公司 Market Taiwan 黃聯 Yellow copy: 經銷商 Distributor 粉紅聯 Pink copy: 推薦人 Sponsor 修訂日期Rev. December 11, 2012