First Name

Middle Name

Last Name

Email

Confirm Email

Cell Phone ex. XXX-XXX-XXXX

Alt Phone ex. XXX-XXX-XXXX

Date of Birth ex. MM-DD-YYYY

SSN ex. XXX-XX-XXXX

Company or DBA

Tax ID or EIN ex. XX-XXXXXXX

Job/Position

School Name

District

Password Requirements:

Does NOT contain your first or last name.
Does contain at least 8 characters in length.
Does contain a number, special character, upper case letter, and lower case letter.

Password

Confirm Password

Physical

Address

Begin by selecting your state

State

City

Zip

Mailing

Same as Physical

Address

Begin by selecting your state

State

City

Zip

Who is your upline?

Upline percentage must equal 100 between both uplines.
Upline 1 number and upline 2 number cannot match.

Upline 1 (Trainer) Number

Upline 1 Percent

Upline 2 (Recruiter) Number

Upline 2 Percent

Are you a US citizen?

Yes No

Are you authorized to work in the United States?

Yes No

Upload Proof (VISA..ect)

Are you insurance licensed?

Yes

Resident License State

Resident License Number

Do you have a health insurance license?

Yes No

Health Insurance License Number

Are you securities licensed?

Yes No

What type of license?

How did you hear about us

CCPA Privacy Notice

Background Information

Yes No

If yes, please explain:

State

License Number

Texas Temporary License?

Yes No

Criminal History Questionnaire

Click here to download and review document.

Please review the above document before answering the following questions.

Applicant Name

Yes No

If you answered Yes, provide city, county, and state of conviction and date and nature of the offense, along with sentencing information.

Signature

Agreements

Click here to download and review document.

I agree

Please check "I agree" at the bottom of each disclosure after reviewing.

Signature

Assessment

Signature

ACH Deposit Information

Account Name

Account Type

Account Number

Routing Number

W-9 Information

Click here to download and review document.

Name (as shown on your income tax return)

Business name/disregarded entity name, if different from above

Check appropriate box for federal tax classification; check only one of the following seven boxes: Individual/Sole Proprietor or Single-Member LLC C Corporation S Corporation Partnership Trust/estate Limited Liability company. Enter the tax classification (C=C Corporation, S=S Corporation, P=Partnership) Other (see instructions)

Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

List account number(s) here (optional)

Payment Details

Choose registration package:

Wholesale Agent Registration: Includes 10 PERA appointments and contracting Wholesale Contracting Only: Includes wholesale carrier contracting fees and library of presentation materials for K-12 appointments

(Nonrefundable)

This Page Is Secure.

Currently accepting the following cards:

Here are some of the ways protects your information:

Our website uses 256-bit Secure Socket Layer (SSL) encryption to transmit your information.
Your financial information is never divulged to anyone.
All transactions are processed by a Payment Card Industry (PCI) Level 1 compliant processor.
We do not store your credit card information.

Enter your credit card information

Card Type Card Number Expiration Date (mm/yy) Cardholder's Name Card Validation Code

Billing Zip

Congratulations!

Welcome to the team! Your registration is now being processed. Welcome to the team! Your payment has been successfully submitted and your registration is now being processed. You will receive a payment confirmation email shortly. As part of the Appreciation Financial System your registration fee has been waived for the first 45 days. If you submit two pieces of business through the back office during this time you will not have to pay a registration fee. If you do not submit two pieces of business through the back office within your first 45 days, you will be required to pay the registration fee of $225 to continue to have access to your Appreciation Financial back office.

Payment Information

Transaction #:

Authorization Code:

Credit Card Number:

Amount:

Password Requirements:

Physical

Begin by selecting your state

Mailing

Begin by selecting your state

Background Information

Criminal History Questionnaire

Please review the above document before answering the following questions.

Agreements

Please check "I agree" at the bottom of each disclosure after reviewing.

Assessment

ACH Deposit Information

W-9 Information

Payment Details

Choose registration package:

Congratulations!

Payment Information

Congratulations!

Welcome to the team! Please wait until your AVP approves your AF Lite Account. You will receive a confirmation email shortly.