Distribution Network Application

First Name       M.I.      Last Name   

Address           Apt. #   

City                 State      Zip Code   

Email Address   

Primary Phone #    --
Alternate Phone #  --

Former Employers (List last four employers starting with most recent)

Date               Name & Address of Employer              Position                         Reason For Leaving

References (List below the names of three persons not related to you, whom you have known at least one year.)

Name                             Address                                              Business                         Years Acquainted

Have you ever been convicted of any criminal offense other than minor traffic violations?Yes No
If yes, list all convictions.
Charge                           Result                            City,State of Conviction                       Date of Conviction

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT MISREPRESENTATION OR OMISSION OF FACTS CALLED FOR IS CAUSE FOR DISAPPROVAL. FURTHER, I UNDERSTAND AND AGREE THAT MY STATUS IS THAT OF AN INDEPENDENT CONTRACTOR AND AS SUCH, I AM RESPONSIBLE FOR ALL TAX LIABILITIES PERTAINING TO MONIES RECEIVED IN THE COURSE OF SERVICES I PERFORM.

Type your initials here to give consent    

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When you click submit and your application has been successfully submitted and you will be re-directed to the Home Page.