Get documents about "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
