Advantage Services
Ephedrine Identification Requirements Form

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. If missing information we will not process your order.

Please Fax this form to us at (704) 593-1597
or Return by Mail to Advantage Services – 8613 Quay Road – Concord, NC 28027
or scan and Email to mini_form@advantageservice.net

Name: _________________________________________________________________________________

Current Address: _________________________________________________________________________

City: ______________________________________________ State: _____________________

Zip: ____________

Driver's License Number: ___________________________________________________

Date of Birth: _____ /_____ / _________

Phone Number: ___________________________________________________________
(Phone number must be listed to current address. No business phone, cell or mobile numbers.)

Advantage Services / Disclaimer

Anyone suffering a serious illness should consult with a doctor, naturopath, nutritionist or similar professional when starting any type of dietary supplement program.
The nutritional supplements offered on this site are not offered as a cure for their associated conditions, but only as a means of helping the bodies own healing potential correct itself of any underlying deficiencies.
Taking more than the recommended serving may result in heart attack, stroke, seizure or death. Consult a health care practitioner prior to use if you have high blood pressure, heart or thyroid disease, diabetes, difficulty urinating, prostate enlargement, or glaucoma, or are using any prescription drug. Do not use if you are taking a MAO inhibitor or any allergy, asthma, or cold medication containing ephedrine, pseudoephedrine, or phenylpropanolamine. Discontinue use if dizziness, sleeplessness, loss of appetite, or nausea occurs.

The consumer assumes all responsibility for the proper selection and use of any nutritional supplement purchased from this site.
 

Signature: _____________________________________________        Date: _______ /_______ /________
                                    Signature is mandatory

ONLY One form of identification must be selected from either Class 1 or Class 2
AND a copy must be attached here where indicated.

 
Class 1  

Please attach a copy of your
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.