Australian Site
APPLICATION FOR AFFILIATE
Please print 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.au/ and clicking on the
Networking
link.
Date
Signed
