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					                                                                                Sales Rep:____________
                                   eChips Online, L.L.C.
                           Membership Registration Form
                                  (For Independent Brokers and Distributors)


Complete and Fax to: (253) 330-8602


Company Name: _______________________________Date:______________
Contact Name:____________________________ Title:___________________
Address:_________________________________________________________
Phone: (____)__________ Fax: (____)__________ eMail:________________
User ID Name: __________________                           (new)Password:____________________

AGREEMENT: I authorize the above company to become a subscribed member of eChips Online, LLC, and
agree to pay on time according to one of the payment plans below. I understand that this signed registration
form commits our company to an ongoing subscription membership. I have read, understand and agree to
uphold in its entirety the Legal Agreement which is posted on the eChipsOnline website. I also understand
should we choose to cancel, we will notify eChips Online in writing 30 days prior to end of membership
term.

Authorized Signature:__________________________ Title:______________


1.         Please Select One Membership Term:

           ___Quarterly Membership               $285.00
           ___Semi-Annual Membership             $570.00
           ___Annual Membership                  $1045.00 *Best Buy* (1 Month Free every year!)

2.         Choose One Payment Method :

     ___Check / USD only                Payable to:        eChips Corporation
                                                           7115 N. Division St. #B173
                                                           Spokane, WA 99208, USA
                                                           (foreign checks, add $25.00 per check)
     ___Credit Card*
                     ___VISA        ___MasterCard           ___American Express             ___Discover

     Credit Card #____________________________ Exp. Date_______Code______
     PRINT Name of Cardholder:___________________________________________
     Billing Address of Card:____________________________________________
     Signature of Cardholder:_____________________________________________
     *(credit cards will automatically be charged at the beginning of each billing term without billing notification)


     ___Wire Transfer                   Please call (253) 330-8601 for bank wire information



                              Thank you for choosing eChips Online
                                                Direct all inquiries to:

              Ph: (253)330-8601           Fax: (253)330-8602         email: support@echipsonline.com

				
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posted:5/2/2011
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