Herbalife International India Pvt LTD.

Condor Mirage
101/1 Richmond Road, Richmond Town
NAME CHANGE REQUEST FORM Bangalore, Karnataka, India - 560025
Tel: (+91 80 4031 1444)
Fax: 080 4031-1445 / 1446

DEEPTI TIWARI
Associate’s Name: _____________________________ W1C693125
Herbalife ID Number: _________________________
(Requestor)

Reason for change - please select one (attachments/information required to process request):

Marriage – Please attach copy of legal marriage certificate

Divorce – Please attach copy of divorce decree

Other – Please attach appropriate legal documentation and specify reason for change:

Please update my name as per my document.

In order to process your request, Herbalife requires that you attach a copy of your new social security
card or Individual Taxpayer Identification Number (which reflects the name indicated below) in addition to
the above-required documentation.

Name should appear as (please indicate in capital letters – 50 characters or less):

DEEPTI

14-06-2021 8840078517
Associate’s Signature Date Telephone Number

NAME CHANGE - India

Revision: 05/11/10