 | ||||
| ||||
| ||||
| ||||
| ||||
APLICACIÖN-DISTRIBUIDOR
AMERICAN VISION HEALTH PLUS
Distribuitor (Sponsor) Name:
Distribuitor (Sponsor) ID:
APPLICATION-DISTRIBUTOR
1631 East Vine Street Suite C Kissimmee, Florida 34744
PH: 1-800-370-7054
Fax: 407-350-5749
Fecha / Date:
FIRST NAME / Nombre
MIDDLE NAME - Inicial
LAST NAME / Apellido
DOB / FECHA DE NACIMIENTO
SOCIAL SECURITY / SEGURO SOCIAL
E:MAIL
MAILING ADDRESS / DIRECCION
CITY / CIUDAD
STATE / ESTADO
ZIP CODE
HOME PHONE / TELEFONO CASA:
CELLULAR PHONE / TELEFONO CELULAR
Credit Card Authorization For Monthly Payments
Card Type
Credit Card Number
S. Code
Expiration Date
mm / yy
Name as it apperrs on the Credit Card
Billing Address
City
State
Zip Code
Appoved
Print Name
Date
mm/day/ yy
mm/day/yy
Email:contact@avhplus.com
www.avhplus.com
| ||||
TOTAL $129.90
SECUNDARY PHONE
FAMILY INFORMATION
Información FamiliarRELATIVES
FAMILIARES
FIRST NAME
NOMBRE
LAST NAME
APELLIDOS
INITIAL
INICIAL
DOB
FECHA NACIMIENTO
GENDER
Sexo 9F0 (M)
RELATION
Relación
SPOUSE
Conyuge
1 DEPENDENT
2 DEPENDENT
3 DEPENDENT
4 DEPENDENT
5 DEPENDENT
PAYMENT INFORMATION
(Información de Pago)
Total Plan A: (LTC Membership & Business Kit)
(Amount selected above is to be drafted immediately)
Medical Discount Plan
(Your Account Will Be Drafted Monthly After 1st Month)
| ||||
Autorización De Su Tarjeta De Crédito Para Los Pagos De Los Proximos Meses
For your Records
Double click here to add text.
$129.90 PLAN DE DISTRIBUIDOR
PAGUE HOY AQUI
Total Pan A: (LTC Membership & Business Kit)
(Amount selected above is to be drafted immediately)
(Pay Today)
$129.90 DISTRBUITOR PLAN
1
2
3
1
.© Copyright 2018 American Vision Health Plus Inc.All Right Reserved
PH: 1-800-370-7054
407-505-0605
American Vision
Health Plus
