Product Order Form Effective 22nd of May 2012

Enogic Distributor ID

(Office use only)

Applicants Information / Informatia Clientului (litere de tipar!)

SAND ALI 22/1(

Firstname/Numele Surname /Prenumele Company "s name/Numele Firmei Date of birth/Data nasterii

VIS 2 550091 SIBIU ROMANIA Street/Strada si numarul Zip code/Cod postal City/Localitatea Country/Tara

Shipping adress/Adresa de livrare (completezi numai daca este diferita de adresa Clientului)

+407 t217 +407 217

Phone #1 Telefonul Fax #1 Nr de FAX Mobile # / Nr Mobil

ynna_ 'ioo.com

E-Mail/ A—dresa de email VAT-number! Numarul del VA (pentru firme)

Sponsor Info/Informatia SponsoruIui E-Mail djboto1©hotmail.com

Nume: BOTOROAGA SORIN RADU ID: 4056774 Tel#: +40 723 955 935

Gradul Distribuitorului: [ 2 A

LeveLuk SD501 EURO 2780 i JR II EURO 1680

LeveLuk SD501 Platinum EURO 3000 Anespa EURO 1680

Single Payment / Pret Intreg

Hrice/Pret

Supplies VAT/TVA

Shipping/

Transport

Total EURO

E-Payment / Rate (E-Payment Form)/Completeaza E-Payment

Hnce/Pret 1680

Supplies

VAT 19%/TVA 319,20

Installment/Rata 150

Shipping/Transport 34

Total EURO 633,20

Down payment 599,20

Numar de Rate: 3 / 6 /0/ 16

Carti CREDIT 0 Visa 0 MC 0 Amex 0 Wire Transfer (Incercuiti Unul)

Credit Card No./ Nr Cartii de Credit CVV/Nr Verificare Valid till/Valid pana

I certify that I have read, understand and agree to the Terms and Conditions set forth in the following documents which comprise the Contract, the Distributor Agreement, the Sales

Contract, Polices and Procedures, Compensation Plan and the Products. I am of legal age in rep state of residence. I agree that any false and mioIeadig statement(s) may result in the termination or denial of

registration as an Enagic Europe distributor. I understand that the financial reward will come from sales of products and not by recruiting people. I, th sponsor, have explained to the applicant all relevant

information which the applicant should know prior to signing up. In addition, as a selling distributor, I acknowledge that I have a good faith duty to asssi nagic Europe in causing the customer to honor their

payment obligation. At the very least. I agree to contact the customer in person or by telephone no less than three times to request that the customer efiYments as required in the customer contract.

20/01/2016

20/01/2016 Semnatura Aplicantuj Date (TT/MM/JJ)

Semnatura Sponsorului Date (TT/MM/JJ)

Commerzbank

Name: Enagic Europe GmbH

KTO: 180321200 BLZ: 30040000 IBAN: DE64300400000180321200 SWIFT: COBADEFFXXX

Enagic Europe GmbH

Immermannstr. 33

40210 Dusseldorf Germany

Tel +49-(0)211-936570-00

Fax +49-(o)211-936570-27

germany_Qenagic-europe.com

Tax-No: 133/5821/1603

Ust-ID No, DE814980514

Commercial Register :

Amtsgericht DOsseldorf HRB 58900

410* Enagic

Enagic Payment - Automatic Payment Application for an Individual Account

Important! Platesti in prezent alt aparat folosind imprumut de la Enagic? EDa / Nu

Effective 11th of October 2011

Office Use Only

Distributor ID Product Notice to Applicants! Print clearly, use dark Unit Price Installment Charge ink. Provide all informations requested Down Payment

Aplicantii trebuie sa citeasca instructiunile inainte sa completeze aplicatial

Applicant Information/Informatia Aplicantului Alternate Payer Information

Name/Numele SANE NI CA Alternate payer name

Str/Strada VISI 22 Street

Cod 550091 Loc SIBIU Zip City

Tel +40 741 934 217 IFax Tel IFax

E-Mail ynna__. . E-Mail

Occupation MED,_, , _INTENT Occupation

Numele Firmei: SPE -T:1 7BIU Current Employers name

Adresa: C. NOICA NR.20 Street

Cod 550240 toc: SIBIU Zip City

Tel. 02 53 lAni lucrati al firma: 1999 Tel. Years with Employer

Monthly pmt/Rata lunara: 150 Nr Pmts/Nr de Rate: 3 06 F7110 F116 Data Platii: 1st 15th Data Primei Rate: 01/03/2016 UltimaRata: 01/12/2016

Informatia Cartii de Credit: EiVisa Mastercard nAmerican Express

Nr Cartii de Credit: 5299 8020 Expira: 12/16 101 CVV

Bank account (only wire transfers, enagic will not withdraw the money automatically)

Please write down also your ID Number, when you transfer your monthly payment to our account.

Numele Bancii: Cont: IBAN:

Directions 1. Although it is possible to alter the number of payments, the installment charge is not refundable. You will also be charged the difference in the

amount of the installment charge if you change to a longer payment plan.

2. A 20€ charge will be asessed for credit card accounts that expire and are not updated in our system. Please update us as soon as possible should

there be any change to your payment information.

3. A 25C late charge will be asessed for each missed payment.

4. Please note that your file will be passed on to a collection agency in case your amount falls past due.

I authorize Enagic Europe GmbH to debit the amount i have indicated above from my credit card. This agreement will remain in effect until the

balance of my payment is paid in full

I hereby certify that the information provided on this Payment Application is complete and accurate to the best of my knowledge.

I have read the directions and agree to the terms and conditions

Semanatura Aplicantului: Alternate Payer Signature

/ Nume: 54* Data: 26 ciicipame Date

Commerzbank

Name: Enagic Europe GmbH

KTO: 180321200 BLZ: 30040000

IBAN: DE64300400000180321200

SWIFT: COBADEFFXXX

Enagic Europe GmbH

Immernnannstr. 33

40210 Dusseldorf Germany

Tel +49-(0)211-936570-00

Fax +49-(0)211-936570-27

germany@enagic-europe.com

Tax-No: 133/5821/1603

Ust-ID No. DE814980514

Commercial Register :

Amtsgericht Dusseldorf HRB 58900

BT BANCA TRANSILVANIA \./

Se va complete de catre banca DISPOZITIE DE TRANSFER Ref. bancara

1. ORDONATOR

Denumire/Nume si prenume Yrt-13 :5) Cod CAEN Localitate

- Telefon f)-?-1 . 1 , Fa)

s tr. tit

I i Cod unic de Inregistrare

CNP 271- =7. - nr. 22._

e-mail

2. BANCA ORDONATORULUI Banca Transilvania S.A. Sucursala/Agentia

Cod

3. SUMA TOTALA ORDONATA

e-79 G,P—*trE77-1-#1?-tei5)17/3R; 00,0 Valuta

(in cifre) (In litete)

din care, plati pe tipuri de tranzactii:

Ni. Valoarea tranzactiei , Descrierea tranzactiei pentru care Data Ni. din Reg. cit. (in cifre) se dispunelefectueaza plata livraril Datoriei externe

I 6'-'3 r?-re 1-1,0C;I ?1"794 FMT 2-F-VR - / — a IC

I / Alitirge__ itc3s977

____ _ _

• 7 in cazui in care numarui ae ranoun am races esre insurIcienr, se vor anexa peon! supnmenrate.

4. INSTRUCTIUNI ALE CLIENTULUI PRIVIND PLATA

Spot I SWIFT/ telegrafic I I Numerar Cec Incasso

I I Urgent I I Confirmare a instructiunii Ordin de plat I I Acreditiv telefonice/ electronice nr.

Pocumente: Plata se oAdspa din:

cont nr. _JC.V"I4 t963e_gh

Contracte

Facturi:

DVI:

Anexa continand lista altor documente necesare efectuarii platii

Comisioane i speze OUR fl BEN 5A SHA

5. BANCA BENEMIARULUI • Denumire

Adresa *9)Lrt%,?;/C-i-r7 731,1G57f2....09RF 6d'e&

Tara G" 14-

7. Tara parteneruLyi din contractui extern

6. BENEFICIAR Ni. cont. 7) E Cit- .3000eeao/4703 2- 12,00 Denumire/ zI 01./Atel Nume Adresa r-fE-R---fr'*pOt/574

470 2-10

Tara OF-P-6 1791-e

Mesaj pentru beneficiar

8. Informatiile complete pe acest formular sunt reale si complete.

Semnatura ordonatorului:

Data '76 -(c)ik -2-69 4-fo stary‘i-i -a

9. Se c4tliple%z ,..A.

Dis.Vde plata'a.N, . :•,,J.-- .v.alutei. . .,

10-"ri _ ,-.eter.,*,',.' ,---- . -

Data

.. ,‘,.....

de catre banca ordonatorului 3t executata

4- s (. (4,2 fo

Semnatura istampila band