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 -- if your consultant is not in the area, 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

Basic Kit $250 Value *Not available.

Standard Kit $525 Value

Select Your Starter Kit: *

Standard Kit $159 + $19.95 s/h + Tax Deluxe Kit $319 + $19.95 s/h + Tax Premium Kit $479 + $19.95 s/h + Tax

Deluxe Kit $1,059 Value

Premium Kit $1,529 Value

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

Expiration Date (MM/YY) *

Security Code on Back *

Name on Credit Card *