Credit Boost America

Independent Sales Associate Agreement

Enrollment Application

* Required

First name *		M.I. Last name *
Street Address *		Apt/Suite #
City *	State *	Zip Code *
	-Work Phone1 and Work Phone 2 will appear on your self replicating website
Work Phone1 #	Ext:	Home Phone #*
Work Phone2 #	Ext:	Cell Phone #*
Fax #	Email Address *
Date of Birth	(mm/dd/yyyy) Start Date	Expiry Date

	-Please note: Commission payment will be issued in this name
Select option
Applicant ID Number If you are enrolling as an individual, please enroll with your SSN, otherwise if enrolling as a business, please provide Federal Tax ID # and company name. All documentation, including your 1099 Form, will reflect the name and number provided.
SSN or Tax ID #	Company

Associate Website for Online Marketing (Optional)

I would like to add the Associate Website for $300 to my enrollment.

Amount

$ ( e.g. 199)

I authorize Credit Boost America to charge my credit card or checking account in the amount of $199.By adding the optional Associate Website to my enrollment, the total amount I authorize Credit Boost America to charge my credit card or checking account in the amount of $499.

Payment Information

Payment Method All fields are required.

Name On Card
Credit Card Type
Card Number	Exp Date (mm/yy) CVV Code
Click checkbox if Billing Address same as above
Billing Address
City	State	Zip Code

Routing #		Account #
Check #		SSN or Tax ID
Click checkbox if Billing Address same as above
Name On Check		Address On Check
Phone #		City
State		Zip Code

If you were referred by another Credit Boost America Associate, please enter the Referring Associate's ID below.
Referring Associate ID

I have read, understand and accept the Terms and Conditions of the above Agreement.