CLUBG
MEMBERSHIP FORM

PERSONAL INFORMATION

Title: (Please check)                        Ms. __ Mrs. __ Mr. __

First Name:                                      ___________________________________

Middle Name:                                  ___________________________________

Last Name:                                      ___________________________________

Birthday:                                          ___________________________________

                                                                                    Month / Day / Year

Home Address:                              ___________________________________

City:                                                   ___________________________________

Province & ZIP:                              ____________________________________

Tel. No. (Home):                              ____________________________________

Office Address:                             _____________________________________

Tel. No. (Office):                            _____________________________________

Mobile Phone No.:                         ____________________________________

Fax:                                                  _________  Email address:     ____________

__ Subscribe me to the FREE Beauty Bulletin e-newsletter

Note:  Once completed, please print and fax form to 896-7945 and a sales associate will contact you shortly.

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I would like to be a: PLATINUM _______  GOLD ________  SILVER  ________ charter member and enjoy my FREE BONUS POINTS.

____ Please ask your sales associate to contact me.

____ I will visit Godiva Skin Station on ________________ to claim my Club G membership.