Name ____________________________________________________________________
ICS ID# _______________________________________
Address ___________________________________________________________________________________________________
City __________________________ State ____________________ Zip ___________________

Telephone number ________________________________ Fax ______________________
SS# _______________________________

Name ____________________________________________________________________
ICS retail customer ID# ________________________
Address _____________________________________________________________
City ___________________________________________ State ____________________ Zip__________________________

Telephone number ________________________________ Fax ______________________ SS # __________________________

Reason for return: ___________________________________________________________________________________________
Return authorization # __________________________ (Obtain by calling Member-distributor services at 1-800-XXX-XXXX)

Product returned: Product* Qty:________
Description ____________________________________________________
Product* Qty:________
Description ____________________________________________________

Amount refunded by Member-distributor to customer: $___________ *

Please allow 5-7 business days for replacement product.

Member-distributor signature _____________________________________
Date ____________________

Customer signature ___________________________________________________
Date ____________________