Welcome to 10-10 International

 

Application for Lifetime Membership

NAME: ____________________________________________               10-10: ______________                 CALL: ________________

ADDRESS: _____________________________________________________________                               APT: _________________

CITY: ____________________________________________                    STATE: __________                     ZIP: __________________

Plan ID
CK           Payments

Plan 1

Plan 2
      1             2

Plan 3
     1               2              3             4

 

US-Life

$500

$260

$250

$130

$130

$125

$125

 

DX-Life

$650

$335

$325

$170

$170

$160

$160

 

US-Senior Life

$150

$85

$75

N/A

N/A

N/A

N/A

 

DX-Senior Life

$200

$110

$100

N/A

N/A

N/A

N/A

Plan 1 - Lifetime Membership in 10-10 International Net, Inc. Enclosed is check, money order or charge information in the amount indicated above under Plan 1.

Plan 2 - Lifetime Membership in 10-10 International Net, Inc. on a two payment plan. Enclose the amount indicated above under Plan 2, Payment 1 in the form of a check, money order or charge information. The balance to be paid within one year of this application date.

Plan 3 – NOT available for Senior Life membership. Lifetime Membership in 10-10 International Net, Inc. on a four payment plan. Enclose the amount indicated above under Plan 3, Payment 1 in the form of a check, money order or charge information. The second payment is due within six (6) month of this application date. The third payment is due within one year of this application date. The fourth payment is due within 18 month of this application date.

Plan 2 and Plan 3 include a record keeping fee of Ten Dollars ($10.00). The applicant understands that lifetime membership will not be granted until membership is paid in full.

Email Address for a payment reminder ________________________________

Method of payment (circle one):   Check  /  Money Order  /  Visa  /  MasterCard

APPLICANTS SIGNATURE: ___________________________________________________________ DATE: ____________________

Credit card information will appear on your statement as RSVP Omaha NE.

Account number below (please include all numbers on your credit card)


_____ _____ _____ _____ - _____ _____ _____ _____ - _____ _____ _____ _____ - _____ _____ _____ _____

Expiration Date: _____ _____ - _____ _____

PHONE NUMBER _____________________________________

CARDHOLDERS NAME IF DIFFERENT FROM APPLICANT (Please Print):________________________________________

 CARDHOLDERS SIGNATURE: _________________________________________________ DATE: ____________________

   You can FAX the completed application to: 402-393-6117

OR

You can mail the completed application to:

10-10 International Net, Inc,
643 N 98th Street #142
Omaha, NE 68114-2342
© Copyright 2008 10-10 International.

 

© Copyright 2008 10-10 International.