Become Our Affiliate
To become our Affiliate, please complete the Affiliate Application Form and submit it to us. We will contact you soon.
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LAVI ENTERPRISES, LLC
APPLICATION
General Contact Information (Please include AREA CODES):
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DAYTIME PHONE:
EVENING PHONE:
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MOBILE:
FAX:
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EMAIL:
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What is your preferred Contact Number?
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Location of your office (s)
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City/Country:
State:
Zip:
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How did you hear about us?
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Have you ever provided Weight Loss Products in your office?
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Are you interested in providing Smart for Life TM Meal Replacement Cookies in your
office?
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Are you a Chiropractor?
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Licensed State/Province:
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Address:
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City:
State:
Zip:
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Do you have a website?
URL:
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Comments:
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Date:
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DISCLOSURE: A CONSUMER REPORT MAY BE PROCURED FOR BUSINESS PURPOSES.
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I voluntarily and knowingly authorize for business purposes only any: administrator,
law enforcement agency, state agency, credit bureau, private business, personal
reference, and/or other persons, to give records or information they may have concerning
criminal history, credit history, or any other information requested. I voluntarily
and knowingly unconditionally release any named or unnamed informant from any and
all liability resulting from the furnishing of this information. A photographic
or faxed copy of the authorization shall serve as valid as the original. It is understood
that the applicant supplies information contained herein to the best of his/her
knowledge and ability. The applicant also agrees to have all information confirmed
by LAVI ENTERPRISES, LLC Executive Committee and to allow them to conduct additional
credit checks and background checks as may be required. Please complete one form
for each applicant.
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Full Name (if sole proprietor)
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Full Company Name (If Inc., LCC or partnership):
State of Incorporation
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State License Number
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Authorized Member of corporation
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Street address
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City, State, Zip
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Social Security Number or EIN Number
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Tax Exempt Number
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Date of Birth
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Drivers License Number
State of Issue
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Signature
Date
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