1901 East Edwardsville Road Wood River, IL 62095 Tel: 618-655-9477 Fax: 618-216-4722
NEW BUSINESS OWNER APPLICATION Name: _________________________________ Sponsor: Current Address: STREET CITY
STATE
Phone Number: (
ZIP
)
(
PRIMARY
)
ALTERNATE
Email Address: Social Security or Tax Identification Number:
Package A: Travel & Ecommerce Business (RTA) $199.99 and ($49.95 monthly RTA fee)
Package B: Travel & Ecommerce Business/Mobile Marketing or Travel & GanoVia 20PK $499.99 ($49.95 monthly RTA fee).
Package C: Travel & Ecommerce Business, Mobile Marketing and 20 GanoVia Coffee Pack $799.00 ($49.95 monthly RTA fee)
Package D: Z/MOBILE 3000
$149.00 ($99.00 per month)
Package E: Coaches Way (Guarantee & Mentoring
Program) $50.00 per month* (Get 3 and yours is FREE)
Method of Payment: Credit Card or Check
Drivers License Number:
IF PAYING BY CREDIT CARD, PLEASE COMPLETE THE FOLLOWING
Type of Credit Card:
Exp. Date:
Credit Card Number: Name on Credit Card:
Sec. Code: __________________
Billing Address: STREET CITY
STATE
ZIP
IF PAYING BY CHECK, PLEASE COMPLETE THE FOLLOWING
Account Number:
Routing Number
Signature: ________________________________________ Date: