Regulations regarding Ephedrine-containing products are changing daily. In
order that no delays occur on future orders, we are requesting that you complete
this form. We believe this information will satisfy all your future requirements.
INSTRUCTIONS: First print
this form, then fill in your information and attach your identification. The
form must be completed in its entirety. Any missing information will not process
your order.
Please Fax this form to us at (954)943-6422
or Return by Mail to 1stplace-supplements, 5225
NW 89 Drive, Coral Springs, FL 33067
or scan and Email to sales@1stplace-supplements.com
Name: _______________________________________________________________________________________
Current Address: _______________________________________________________________________________
City: ______________________________________________ State:
_____________________ Zip: ____________
Date of Birth: _________ /_________ / _________
Phone Number: ___________________________________________________________
(Phone number must be listed to current address. No business phone numbers.)
Is the phone number listed in your name? Please circle: Yes No
If NO, whose name is it listed in, and what relation are they
to you: ______________________________________
Signature: _____________________________________________
Date: _________ /_________ / _________
Signature is mandatory
Driver's License Number:
___________________________________________________
One form of identification must be selected from both Class 1 and Class
2
AND a copy must be attached here where indicated.
Class 1
DRIVER’S LICENSE or STATE ID CARD HERE
Address of Driver’s License/State ID Card must match current address
No Exceptions
Class 2
Please attach copy of your PERSONAL ID HERE
(other than what you used for Class 1)
For example: Vehicle Registration Card, Passport,
Social Security Card, Voter Registration Card,
or State Identification Card
By completing this form you are acknowledging that the information you
supplied is correct.