Qivana Pre-launch Application

YOUR SUCCESS IS OUR FOCUS

Qivana was created with a single, solitary goal in mind—to make the success of Independent Business Owners the top priority.

THE COMPANY Qivana’s founders possess a wealth of experience in the network marketing industry that is second to none. Their past companies read like a Who’s Who of network marketing powerhouses: NuSkin, Tahitian Noni International and XanGo. They understand the necessary components to build a successful company that empowers Independent Business Owners to take control of their lives—to create their own destinies. And it is this understanding and experience that make Qivana so exciting.

THE PRODUCT Qivana delivers the highest-quality products in the industry. Working in conjunction with renowned naturopathic physician Dr. Marcus Laux, Qivana delivers products composed of the world’s greatest botanicals—all validated by modern science and extensive research. Dr. Laux has spent the last 20 years travelling to all ends of the earth to find the most effective therapies nature has to offer. It is his knowledge of botanicals and natural ingredients that helped develop the philosophy behind Qivana’s synergistic system—a system that is intended to deliver the benefits you need. The system features three simple steps:

probiotic

essentials

detox detox

STABILIZES YOUR INTESTINAL

VITALIZES YOUR BODY WITH A

OPTIMIZES YOUR OVERALL HEALTH

TRACT THAT ENHANCES THE

UNIQUE BLEND OF ASIAN HERBS

BY REMOVING HARMFUL TOXINS

IMMUNE SYSTEM AND AIDES IN

DESIGNED TO HELP YOU REACH

AND HEAVY METALS FROM YOUR

ABSORPTION OF NUTRIENTS

YOUR BIOGENETIC POTENTIAL.

BODY WITHOUT DEPLETING IT OF ESSENTIAL MINERALS.

THE OPPORTUNITY Qivana presents an opportunity that is focused on the success of everyone who joins the company as an Independent Business Owner. When you combine a dynamic compensation plan that has been proven to provide long-term success with a product system that encourages long-term participation, you have an opportunity that is unique and exciting. You can take control of your circumstances and create balance in your life. You can help those you know understand that there can be some much more. You can be a better you. And Qivana is the vehicle. At Qivana, your success is our business. There is no time to wait. Start living your life—the life that you choose—today.

application APPLICANT/CO-APPLICANT INFORMATION Applicant Name (legal name):____________________________________________________________________________________ SS#___________________________Date of Birth ____________________Email:__________________________________________ Day Phone:_______________________Evening Phone:____________________________Cell Phone:___________________________ Co-Applicant’s Name (if applicable):_______________________________________Co-Applicant Date of Birth___________________ Business/Entity Name (if applicable):______________________________________EIN or Fed ID #:___________________________ Shipping Address (no PO boxes): _______________________________City ____________State____________Zip________________ Billing Address* (if different) ___________________________________City ____________State____________Zip_______________ *BILLING ADDRESS CAN BE PO BOX OR APO

SPONSOR/PLACEMENT INFORMATION Sponsor Name______________________________Sponsor ID Number__________________________ Placement Name*____________________________Placement ID Number________________________

Position: [ ] Left [ ] Right

*IF PLACEMENT INFORMATION IS NOT KNOWN, PLEASE LEAVE BLANK AND YOU WILL BE PLACED IN YOUR SPONSOR’S FIRST AVAILABLE POSITION

ORDER/AUTOSHIP INFORMATION Select an Initial Order* (delivered to shipping address):

Select an AutoShip Order (delivered to shipping address):

[X] Pre-enrollment and Sign-up Fee Only** $59.95 [ ] Business Max*** $1,000/1,000PV (16 person, 30 day-supply)

[ ] Qore Share $250/225PV (4 person, 30-day supply)

[ ] Business*** $500/450PV (8 person, 30-day supply)

[ ] Qore Standard $130/100PV (2 person, 30-day supply)

[ ] Qore Share*** $250/225PV (4 person, 30-day supply)

[ ] Qore Single $65/50PV (1 person, 30-day supply)

*ALL ORDERS ARE SUBJECT TO SHIPPING AND HANDLING CHARGES, AS WELL AS THE LOCAL SALES TAX OF THE ENROLLEE’S REGION, AND WILL BE ADDED TO THE ORDER TOTAL **SIGN-UP FEE INCLUDES DISTRIBUTOR KIT, WHICH CONTAINS SALES MATERIALS AND QIVANA COMPANY INFORMATION ***BUSINESS MAX, BUSINESS AND QORE SHARE INITIAL ORDERS QUALIFY FOR QUICK START AND BUILDER BONUS COMMISSIONS

PAYMENT INFORMATION Credit Card Number (MC, Visa, Amex, Discover)___________________________Exp Date___________ Security Code*____________ Name (as shown on card)__________________________________Cardholder Signature_____________________________________ *THE SECURITY CODE IS FOUND ON THE BACK OF MASTERCARD, VISA AND DISCOVER CARDS (3 DIGITS FOLLOWING THE CREDIT CARD NUMBER), AND ON THE FRONT OF AMERICAN EXPRESS CARDS (4 DIGIT NUMBER ABOVE THE CREDIT CARD NUMBER)

[ ] I understand that any commissions I earn will be loaded directly on to my Qivana Pay Card (no check will be received) [ ] I understand that all pre-enrollment orders (orders placed on this form) will ship at the end of April 2009 [ ] I understand that my provided credit card will be charged automatically for AutoShip orders on a rolling 4-week schedule [ ] I agree to the Qivana policies and procedures Signature_________________________________________________________________Date_________________________________ Signature_________________________________________________________________Date_________________________________

For any questions, or help filling out this application, please contact Qivana Customer Service at

1-888-8QIVANA (1-888-874-8262)