New Media Distributor Application Form

Please print and complete the New Media Distributorship Application Form below, and then mail or fax it to the address / fax number indicated on the form. Retain a copy for your records.

If you prefer, an original application form can be mailed to you instead. E-mail us (with your complete mailing address) at J & D Enterprises, and we'll send the form to you right away!

You will receive your new distributor package in 4 to 6 weeks after you submit the application.



NEW MEDIA DISTRIBUTORSHIP APPLICATION FORM


Sponsoring Premium Distributor's Name: John A. Beresh, Jr.
Client Number: 1420778
NAME AND SHIPPING INFORMATION

Name___________________________________________ Date__________________

Address________________________________________________________________

Address________________________________________________________________

City__________________________________ State_______________ Zip___________

Phone__________________________________________________________________

FAX____________________________________________________________________

E-Mail__________________________________________________________________

PAYMENT METHOD:
[__] Check [__] Money Order [__] AmEx [__] Visa [__] Mastercard [__] Discover

Credit Card Number_______________________________________________________

Expiry Date: _______________________ Signature_______________________________

PRODUCT NAMEQty Cost Ea.Total
The Start Up Package ________$195_________
The Executive Package ________$295_________
The Premium Package ________$495_________
Subtotal _______
Local Sales Tax _______
Shipping _______
Total _______

Add local sales tax for ( CA, UT, NB )
Shipping & Handeling $9.00 per package. ( UPS Ground )

All Packages as described here are subject to terms and conditions of the service agreement.

Please mail or fax this form to:

New Media Telecommunications, Inc
P.O Box 12109
La Jolla, California 92039-2109
FAX (619) 558-3344


FOR OFFICE USE ONLY

Zero Balance Cards:
Control Numbers____________________to_________________ Total____________
Credit Card Authorization # ____________________________
Date Shipped ________________________Tracking Number_______________________