Australian Site APPLICATION FOR ASSOCIATE OR UPGRADE FROM 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 enrol as Associate or upgrade from Affiliate grade with M. WORSLEY and confirm that the above details are correct. I/We understand that this membership level or reclassification involves an ongoing commitment to engaging in a minimum level of network promotional activity or the payment of a monthly fee to cover the shortfall as outlined on the M. WORSLEY website at http://www.mworsley.com.au/ and clicking on the Networking link. Date   Signed