MWI
2570 W. International Speedway Blvd.,
Daytona Beach, FL 32114 		Independent Representative Application &Agreement
Use this form to sign-up a new representative.
Print this form, sign it and mail with payment. 		CUSTOMER SVC:(904)257-9090
FAX:(904)239-0476
(904)258-8111
Social Security Number:
*OR* FEDERAL ID:
Home Telephone Number:
FAX Number:
First and Last Name: FIRST
LAST .
Company Name:
* IMPORTANT UPS DOES NOT SHIP TO P.O. BOX
Billing Address:
IMPORTANT: UPS DOES NOT SHIP TO P.O. BOXES
Your charge will appear on your bill
as "Marketers World Int'l."
E-mail: Enter a valid email address.
Username: Password:
Sponsor Information: Sponsor/Placement information cannot be changed after submission to the company. Sponsor must provide either SSN, FED ID or Marketers World ID #. List one only (SSN is used by default)
Sponsor's Name: FIRST
LAST
Sponsor's Telephone Number:
Sponsor's Soc. Sec. #/
Marketers World ID:
Enroller Information: (Placement Sponsor - if applicable)
Enroller's Name: FIRST
LAST .
Enroller's Telephone Number:
Enroller's Soc. Sec. #/
Marketers World ID:
Entry Level Options: You must choose one below
Independent Representative: FREE
Rep. Kit $39.00
SPECIAL PACKAGE (must fill out special package order form)
Payment Method: ( *checks and money orders must be mailed attached to this form)
Applications accompanied by personal checks will be held 14 days for processing.
Cashier's Check* MO* Pers. Check* VISA M/C AmEx 		   
If Paying with credit card, please fill out card info and sign at right
You will see a charge on your statement from Marketers World International 		Card #:   Expiration (MM/YY):
Card Holder's Name:

OFFICE USE ONLY:
CT QC DP FM

My signature below indicates that I have read the company's Policies and Procedures and that I willingly accept all terms and conditions of this agreement. As a representative, I understand that I may cancel at any time. Regardless of reason, cancellation must be submitted in writing to the Company's principal place of business. This agreement is not effective until accepted by Marketers World International, Inc. at its principal place of business. No purchase necessary.
SIGNATURE: __________________________________________________
Print this form on ONE PAGE, sign it and mail with payment. Cashier's check, personal check or money order, please.