The American Program
2093 E. Karin CT. #104 Salt Lake City, UT. 84121-7114 *********** Phone 801- 942-8021 Fax 801-947-9743
Please make copies of this form for future monthy voluntary re-entry(s)
Please printIn BOLD INK (BLACK)
Name/Bussiness__________________________________________ Phone:______________________
Address:_________________________________ Fax:__________________
City:____________________________________ ST./PR._____________________________
Country:_______________________ Zip/Postal Code:__________________
SS#/FIN#_______________________________ E-Mail_____________________________
Your sponsors Name:________________________________ Your Sponsors ID#________________________
Check One Of the FOLLOWING:_______Intial entry(s)___________Re-Entry(s)
I would like to order the following(Check One)____ 60 MLM Fax Leads _______30 MLM Mailing Leads with
Phone Numbers (USA. Numbers Only)
_______ 1 Product purchase for $5.00 or, _________ 3 product purchases for $15.00
______I am adding $2 for (master)of the fax-on-demand material to be mailed to me.
______I am adding $5 for a current Genelogy.
PAYMENT METHOD: MAIL Money-Order. (Do not Staple, glue or tape). The Company will not be
RESPONSIBLE for applications sent in CASH!!!
PAYABLE TO: THE AMERICAN PROGRAM
I understand that my first Initial purchase will be in my sponsor's name,and if I make more than one Intial
purchase, therest will be in my name.
I wish to apply and agree to have$5 per month deducted for each entry and re-entry from my PhaseOne 2x6
matrix commisions. Also, $15 $45, and $135 as my double commissions become available for Phase2,3,and 4,
also from my matrix. Any income earned is dependent upon individual efforts; although spillover may occur
from upline efforts. I must sell at least two (2) Lead Packages to qualify for bonus checks. Futhermore, I
understand I may cancel this transaction within 72 hours for any reasons. I must notify the company by fax and
mail, and my purchase price will be refunded. Otherwise, no refund requests will be accepted. All sales are
FINAL.
________ Check here to waive the 72 - hour holding period and be entered into the matrix immediately.
SignatureX______________________________ Date:_____________________________
Your ID#______________________________
Email: schriner@essex1.com
