NEW IBO BENEFITS AGREEMENT

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					                                                             NEW IBO BENEFITS AGREEMENT                                                                                                            NUMBER OF SPONSORING IBO
                                   (If you live in South Carolina, Connecticut, Louisiana, Maine, Maryland, North Carolina, Utah
                                             & Washington State, please use the “Alternate New IBO Benefits Agreement.”)
                                                            Applicant’s Social Security Number                              Home Telephone                                                    Mobile Telephone

    GETTING STARTED
                                                           J Mr.
                                                                    First Name                                                       MI      Last Name                                                           Date of Birth
            Basic Independent                              J Mrs.
             Business Owner                                J Ms.
J $20                                                      J Mr.
                                                                    Spouse or Partner’s First Name (Optional for Recognition) MI             Last Name                                                           Date of Birth
J $50 Initial Payment and Recurring IBO
X Registration Fee ~WAIVED!                                J Mrs.
       Benefits Fee - complimentary items included:        J Ms.
       • Four (4) E-Commerce enabled websites               Mailing/Shipping Address (NO P.O. BOXES PLEASE)                                                                                                                   Apt.# or Suite#
       • Dental Plus Program - Household Membership
       • IBO Back Office website
       • Training site www.7corecommittments.com w/eKit
       • Freedom Pass                                       City                                                                                                                                            State         Zip Code

    J $45 IBO Kit - includes:
  OPTIONAL

                                                            Email Address                                                                                                       AmeriPlan may send me
           • Start-Up Supplies
                                          } a $120                                                                                                                                                          Preferred language if $45 IBO Kit is
    J $400 Trainer Option Program (TOP)                                                                                                                                                                     selected: J English J Spanish
           • $75 in Sales Aid Certificates value!                                                                                                                               updates via email (email
                                                                                                                                                                                required)
                                                            LIST OF HOUSEHOLD MEMBERS                          If needed, please attach separate sheet for additional household members.
Total: $ ______________________                             First Name                                                            MI        Last Name                                                            Date of Birth
        (Optional)
   Premium Independent
      Business Owner
J $20
X Registration Fee ~WAIVED!
J $100 Initial Payment & Recurring IBO                     I WANT TO PAY MY MONTHLY OR QUARTERLY MEMBERSHIP FEE BY: (select one)
                                                           J BANK DRAFT:                         J CREDIT CARD:
       Benefits Fee - complimentary items included:
       • Four (4) E-Commerce enabled websites                                                                                 J Visa     J MasterCard                     Expiration Date
                                                                J Voided check attached                                       J Discover J American Express
       • Total Health Program - Household
         Membership
                                                                                                         Credit Card Number                                             Month          Year

J
       • IBO Back Office website
                                                                                                                                                                                                      5700 Democracy Drive • Plano, Texas 75024
       • SecureNet Program* Use the above SS# &
        name to register me, the primary member,                                                                                                                                                                 Fax: 469-229-4595
        automatically for SecureNet ID Monitoring.         By attaching my enclosed voided check and/or my signature                                                                                         stop@stopmembership.com
        EIN/FED #s may not be used to register for ID      below, I authorize a recurring draft of my checking account                 • If your application is processed on the 4th of the
        Monitoring. If using EIN /FED#, you may register   or charge to my credit card account until I notify                            month through the 18th of the same month, your first         Any IBO may cancel their IBO Benefits
        once you receive your SecureNet member guide.
                                                           AmeriPlan® in writing of cancellation.                                        draft will be on the 18th of the following month.            Agreement and receive a full refund if
       • Freedom Pass Plus                                                                                                             • If your application is processed on the 19th of the          AmeriPlan® receives a written notice of
       • AmeriPlan Tax & Money Matters (ATM2 )Club                                                                                       month through the 3rd of the next month, your first          cancellation within 3 days of the date
       • Training site www.7corecommittments.com w/eKit    X                                                                             draft will be on the 3rd of the following month.             the IBO Benefits Agreement is received
                                                             Signature of Credit Card or Bank Account Holder
                                                                                                                                                                                                      by AmeriPlan®. Notifications may be
    J $45 IBO Kit - includes:
  OPTIONAL                                                     MONTHLY OR QUARTERLY PAYMENTS MUST BE MADE BY ELECTRONIC BANK DRAFT OR BY CREDIT CARD.
                                                                 INVOICING IS AVAILABLE FOR ANNUAL MEMBERSHIPS ONLY WITH FIRST YEAR PAID IN ADVANCE.                                                  sent by mail, fax or email.
           • Start-Up Supplies
                                          } a $120
    J $400 Trainer Option Program (TOP)
           • $75 in Sales Aid Certificates value!          I agree to the Terms and Conditions set forth on both sides of this Agreement. Furthermore, this Agreement will automatically renew unless cancelled with a thirty-
                                                           day written notice after the initial year. I understand that this Agreement is on an annual basis and all fees are non-refundable. Under penalties of perjury, I certify
                                                           that: the number shown on this form is my correct social security number or taxpayer identification number. You will receive ID cards and member guide(s) within
Total: $ ______________________                            14 business days.
 *ID   Theft Reimbursement Insurance coverage not          X
 available to residents of New York and may not be           SIGNATURE OF NEW IBO (required)                                                                                                   DATE
 available in other jurisdictions.
                                                                                              (1) AmeriPlan’s Copy (White)                (2) New IBO’s Copy (Yellow)                                                                NIBA_0709