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APPLICATION FOR AFFILIATE

Please either complete this form or if you prefer, you can print a copy of this form and fax to us on +61-3-9974.2047
Name
Ref #
Contact Address
Phone
Fax
Email
Mobile
Bank for Deposits
Bank Address
Account Name
Account Number
Currency
Credit Card for Fee's
 Visa Mastercard Amex Diners 
Card Number
Card Holders Name
Expiry Date
 (MM/YY)
I/We hereby apply to register as an Affiliate with M. WORSLEY and confirm
that the above details are correct. I/We understand that this entry-level
classification involves no ongoing commitment to engaging in a minimum level
of network promotional activity or the payment of a monthly fee and the terms
of an Affiliate are as outlined on the current pages of the M. WORSLEY
website at http://www.mworsley.com/ and clicking on the Networking link.

ABN 64 063 565 451

6 Illawong Grove, Werribee VIC 3030, Australia
Phone: +61-3-9741.8452  Mobile: +61-414-29.4494 
Fax: +61-3-9974.2047
USA Fax +1-815-550-4903
Email: mw@mworsley.com

Home - Profile - Clients - Staff - Contact Us - Networking - International Site