Enrollment (Consultant)

PERSONAL INFORMATION

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Confirm Email

Cell Phone *

Home Phone

CONSULTANT CONFIRMATION DETAILS

Date of Birth *

Example: MM/DD/YYYY

PAYMENT INFORMATION

You can enroll for $19.99 paid Monthly.
If you select Monthly, you'll be charged $19.99 today to activate your consultant account. Each month on the date of Your initial enrollment You'll automatically be charged $19.99 to keep your account active, billed to the credit card you provide today until you cancel. You can cancel anytime by calling 833-VIV-LIFE (833-848-5433).
OR
You can enroll for $99 paid Annually.
If you select Annually, You'll be charged $99 today to activate your consultant account. Each year, on the anniversary of your enrollment, you'll automatically be charged a $99 renewal fee to keep your account active, billed to the credit card you provide today until you cancel. You can cancel anytime by calling 833-VIV-LIFE (833-848-5433).

Select Your Payment Option *

Credit Card Number *

Name On The Credit Card *

Expiration Date *

Example: 10/25

CVV *

The 3 or 4 digit code on the back of the Credit Card

Is The Billing Address The Same As Above? *

CONFIRM CURRENT & RECURRING FUTURE PAYMENTS

Enrollment Confirmation Disclaimer and Acknowledgement *

First

Middle

Last

I UNDERSTAND THAT THERE ARE NO REFUNDS.
I understand that my IP Address is recorded for Fraud Protection.
I certify that the above information contained in this enrollment is correct.
I certify that I am authorized to use the above Credit Card information contained in this enrollment.
I agree to abide by the rules and regulations of the company and never make any false claims to my customers.

Message

9:AM – 5:PM

Dallas, Texas 75001

(833) 4MY-RATE