Enrollment (Affiliate)

PERSONAL INFORMATION

Name *

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Address *

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City

State

Zip Code

Email *

Confirm Email

Cell Phone *

Home Phone

AFFILIATE CONFIRMATION DETAILS

Date of Birth *

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ACKNOWLEDGEMENT

Enrollment Confirmation Disclaimer and Acknowledgement *

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Affiliate Enrollments are Free Forever.
I understand that my IP Address is recorded for Fraud Protection
I certify that the above information contained in this enrollment is correct.
You won't be charged anything. You can cancel anytime by calling 833-VIV-LIFE (833-848-5433).
I agree to abide by the rules and regulations of the company and never make any false claims to my customers.

Name

9:AM – 5:PM

Dallas, Texas 75001

(833) 4MY-RATE