application form

1
Sponsors User Name: _______________ Sponsors Name: ________________ Your Information: Email Address: ____________________________________ First Name : _________________ Last Name: ____________________ Address: _________________________________________________________ Suburb/City : ___________ State: ________ Post Code: ________ Country: _________ Phone Number: _____________ Birth Date:________ Your User Name (5 to 9 Characters) ______________ Password: _____________ If Paying By Credit Card MasterCard / Visa / Cash Card Holders Name ____________________ Expiry Date ______________ Card Number ________________________________ VCN Number (3 Numbers On Back of Card) _________ Pack $390.00 USD [ ] or $195.00 USD [ ] Signing this form you agree that: The above is your Sponsor Your placement in the Company’s Genealogy can’t be changed once processed. Yes . I understand my Purchase is Non Refundable Printed Name _______________ Signature __________________

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CPC Application Form

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Page 1: Application Form

 

 

             

     Sponsors  User  Name:  _______________      Sponsors  Name:  ________________  

     Your  Information:      Email  Address:  ____________________________________  

     First  Name  :  _________________                              Last  Name:    ____________________  

     Address:  _________________________________________________________    

   Suburb/City  :  ___________                        State:  ________                                Post  Code:  ________    

   Country:    _________          Phone  Number:  _____________              Birth  Date:________  

   Your  User  Name  (5  to  9  Characters)  ______________  Password:  _____________  

                               If  Paying  By  Credit  Card                MasterCard  /    Visa  /    Cash  

Card  Holders  Name    ____________________                  Expiry  Date  ______________  

Card  Number      ________________________________                

 VCN  Number  (3  Numbers  On  Back  of  Card)  _________      

 

                                                                       Pack        $390.00  USD    [    ]              or          $195.00  USD    [    ]  

 

Signing  this  form  you  agree  that:  

• The  above  is  your  Sponsor  • Your  placement  in  the  Company’s  Genealogy  can’t  be  changed  once  processed.    • Yes  .  I  understand  my  Purchase  is  Non  Refundable  

   

   Printed  Name    _______________        Signature      __________________