Date: _____/_____/__________ SSN: __ __ __ - __ __ - __ __ __ __ DOB: _____/_____/_______

Company Name (if applicable): ____________________________________________ Tax ID: __________________________

Last Name: _______________________________ First Name: ________________________________ M.I.: _____
Address: _________________________________________________________________________ Apt. No.: _____________
City: _____________________________________________________________ State: ________ Zip: ___________________
Home Phone: _____-______-__________ Work Phone: _____-______-___________ Cell Phone: _____-______-___________
Fax: ______-_______-_______________ Email: _____________________________________________________________
Enrolling IMA: _____________________ IMA No.: ________ Sponsors Name: ______________________ IMA No.: _________
ASSOCIATE INFORMATION (PLEASE PRINT CLEARLY)
PLEASE CHECK ALL BOXES THAT APPLY
10878 Westheimer Rd., Suite 191
Houston, TX 77042
Phone: 1.866.365.5829
Fax: 1.866.837.4556
ACCEPTANCE OF AGREEMENT
A participant in this Network Marketing Plan has the right to cancel at any time, regardless of reason. Cancellation must be submitted in writing to the company at its principal
business address: 10878 Westheimer Rd., Ste. 191, Houston, TX 77042. The terms and conditions are available in the Guide to Financial Freedom and on the website
www.awisima.com. IMAs have three(3) days to review and accept or cancel the IMA Agreement. If the IMA cancels during those three (3) days, a full refund will be issued.
Your signature below indicates that you have carefully read this Agreement and that you willingly accept and agree to all terms and conditions attached herein.
X_______________________________________ Date:___/____/____
Signature of Independent Marketing Associate
BILLING INFORMATION (PLEASE CHOOSE ONLY ONE METHOD OF PAYMENT)
Monthly Associate Dues for
Personal Websites & Administration + $26.00
One-time fee With No Annual Renewal
($25 Associate Kit included in this fee) + $73.00
TOTAL: = _
IMA REPRESENTATIVE PLAN
A membership application is attached.
I am already a Member. My Member ID Number is:
___ ___ ___ - ___ ___ - ___ ___ ___ ___
I choose direct deposit for my commissions. Please use the same banking information
listed below if paying by bank draft. Otherwise, a voided check is attached.
INITIAL PAYMENT INFORMATION
X________________________________________________
Signature of Account Holder
Monthly
Bank Draft or Debit (please choose one) Checking Savings

Name of Account Holder_________________________________________

Bank Name: __________________________________ Bank Transit #: __ __ __ __ __ __ __ __ __ Account #: __________________________
Credit Card VISA MC DISCOVER AMERICAN EXPRESS Account #: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Name as it appears on Credit Card__________________________________
Expiration Date: ____/________ CVV2 #: __ __ __ __
X________________________________________________
Signature of the Depositor or Credit Card Holder. (Must be signed by employer if employer is paying the Associate dues.)
I authorize AWIS, or its designated attorney-in-fact to electronically draft my account or bill my credit card indicated above for my one-time initial payment, and my recurring Associate dues.
Check this box if you
are paying for this
Account and are not
the Associate.
(the last 3 digits on the signature line of your credit card, 4 digits on American Express)
AWI S_I MA_APPLI CATI ON REV:11.30.2011
A Licensed Insurance Agency
THIS PROGRAM IS NOT INSURANCE NOR INTENDED TO REPLACE INSURANCE
Discount Medical Plan Organization
Independent Marketing Associate Agreement