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PRODUCT SALES RECEIPT

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PURCHASED BY: SALESPERSON
_________________________________________________________________________ _____________________________________
LAST NAME FIRST NAME MIDDLE DATE
_________________________________________________________________________ _____________________________________
SOCIAL MARKETER ID# E-MAIL
_________________________________________________________________________ _____________________________________
STREET ADDRESS PHONE
_________________________________________________________________________
CITY STATE ZIP
ITEM # DESCRIPTION QTY PRICE EACH TOTAL
SUBTOTAL
SHIPPING
TOTAL
YOUR MODERE SALESPERSON IS:
______________________________________________________________________________________
Please see the reverse side for a Statement of Cancellation Rights
PRODUCT SALES RECEIPT
Modere • 588 S. 2000 W. • Springville, UT 84663 • Toll Free Customer Service 877-663-3731 • Fax 800-998-7260
PAYMENT OR CREDIT CARD INFORMATION:
r A.C.H. debit (application must be on file with Modere)
r Money order or cashier’s check – amount remitted $__________ (single order only)
r Visa r MC r Amex r Other______________
_____________________________________________________________
CARD NUMBER EXP. DATE
_____________________________________________________________
CARDHOLDER’S SIGNATURE (REQUIRED)
MODERE PRODUCT SALES RECEIPT • ITEM CODE #20001 • 09/13
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NOTICE OF CANCELLATION
Date of transaction ___________________________
You may cancel this transaction, without any penalty or obligation, within three business days (five
business days for Alaska residents) from the above date.
If you cancel, any property traded in, any payments made by you under the contract or sale, and any
negotiable instrument executed by you will be returned within 10 business days following receipt by the
seller of your cancellation notice, and any security interest arising out of the transaction will be canceled.
If you cancel, you must make available to the seller at your residence, in substantially as good condition
as when received, any goods delivered to you under this contract or sale; or you may if you wish, comply
with the instructions of the seller regarding the return shipment of the goods at the seller’s expense and risk.
If you do make the goods available to the seller and the seller does not pick them up within 20 days of the
date of your notice of cancellation, you may retain or dispose of the goods without any further obligation.
If you fail to make the goods available to the seller, or if you agree to return the goods to the seller and fail
to do so, then you remain liable for performance of all obligations under the contract.
To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other
written notice to __________________________________, at __________________________________ not
later than midnight of ____________________.
I hereby cancel this transaction.
Buyer’s signature __________________________________ Date ___________________________
PRODUCT SALES RECEIPT (CONTINUED)
MODERE PRODUCT SALES RECEIPT • ITEM CODE #20001 • 09/13
Modere • 588 S. 2000 W. • Springville, UT 84663 • Toll Free Customer Service 855-663-3731 • Fax 800-998-7260
NAME OF SELLER ADDRESS OF SELLER’S PLACE OF BUSINESS
DAT E
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PRODUCT SALES RECEIPT

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Completed 17 February 2021

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