Enrollment Form

Consultant Enrollment Form

Filling out this form means you are joining the Pure Romance Romance Make It Happen Team based out of Milwaukee, WI, USA - if your consultant is not on our team - please contact her directly! Thank you!
Upon receipt of your enrollment form, your application will be sent to our VIP department within 24 hours.

* Indicates required field

Your Legal Name *

First

Last

Your Preferred Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

*Kits can only be processed in the US and Canada.

Email *

Phone Number (xxx-xxx-xxxx) *

Date of Birth (MM/DD/YY) *

Have you ever Sold Pure Romance before? *

Yes No

How long ago did you sell and under whom? *

What is the Name of the Consultant You are Working with Today? *

Select Your Kit

Select Your Starter Kit: *

Premium Kit $659+ $19.95 s/h + Tax Deluxe Kit $439+ $19.95 s/h + Tax Standard Kit $219+ $19.95 s/h + Tax

Credit Card Number (xxxx-xxxx-xxxx-xxxx) *

Expiration Date (MM/YY) *

Security Code on Back *

Name on Credit Card *

First

Last

Billing Address (if Different from Above) *

Line 1

Line 2

City

State

Zip Code

Country

I have read and agree to the Consultant Agreement below: *

I agree

By clicking submit, you agree to send your enrollment form to our VIP deparment. Your card will be charged once it reaches our VIP dept within 24 to 48 business hours.

Submit

Consultant_Agreement.pdf
File Size:	167 kb
File Type:	pdf

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