Please complete the Internet@ Agent Registration form below and click submit. You will need to complete this form for each exclusive zip code territory you would like to license. if the exclusvie zip code you have chosen is not available, you will be contacted by a Regional Manager to discuss other available zip codes. In that event you will not be under any obligation to chosse another zip code and enroll as a new Agent if you decide not to. If the zip code you have selected is available, it will be licensed to you and you will receive your entire new Agent Welcome Kit within 10 business days of submitting this Registration Form.

Personal Information

APPLICANT - NAME (LAST, FIRST, MIDDLE INITIAL)
NAME OF BUSINESS TYPE OF BUSINESS
SOCIAL SECURITY NUMBER/FEDERAL TAX ID NUMBER 
MAILING ADDRESS  
 
CITY STATE ZIP
PHONE EMAIL ADDRESS
Agent Office Registration

Choose the name of your Agent Office. For example: Internet@"YourAgentName". Please make 3 choices in order of preference in the event that your first choice is taken. The chosen name must also be available as a domain name, for example www.InternetAtYourAgentName.com for your Agent web site. You can visit www.domainfulfillment.com to check for available domain names or you can call Agent Support assistance at (866) 276-2645.

1ST CHOICE: INTERNET@
  
2ND CHOICE: INTERNET@
  
3RD CHOICE: INTERNET@
  
Exclusive Territory

Payment Option
(Select One)
 $2000 (Payment in full)
$1000 down (Two additional payments of $500.00)
$500 down (Eleven additional payments of $137.00)
Please list the Exclusive Zip Code covered by this Agent Registration Form and accompanying Licensing Agreement.
Agent Rubber Stamp

New Agents receive one Internet@ Agent rubber stamp to use to label their product catalogs and brochures.

AGENT OFFICE NAME  
AGENT WEB SITE ADDRESS  
AGENT PHONE NUMBER AGENT E-MAIL ADDDRESS

E-mail Set up

You may have up to 3 e-mail addresses set up for you new Agent Web Site. Your e-mail address could be anyname@"YourAgentWebsite".com and have it directed to an existing active e-mail account such as Hotmail or AOL.

EMAIL ADDDRESS TO BE SET UP:  EMAIL ADDRESS TO BE FORWARDED TO:
EMAIL ADDDRESS TO BE SET UP:  EMAIL ADDRESS TO BE FORWARDED TO:
EMAIL ADDDRESS TO BE SET UP:  EMAIL ADDRESS TO BE FORWARDED TO:

Agent Business Cards

New Agents receive one set of Agent Business Cards included at no charge. Please fill out the information below to be included on your business cards. Information you do not put down will simply be excluded.

NAME
TITLE  
 
AGENT OFFICE NAME
ADDRESS  
 
CITY STATE ZIP
PHONE FAX
WEB SITE ADDRESS E-MAIL ADDRESS

Web Site Development

Your Agent Web Site will be branded to your chosen Agent Office name listed above. Sales Contact information is to be displayed on your Agent Web Site and is to be your Agent information that is supplied by you. Customer Service information is already listed on your web site and does not involve Agent. Please list any Sales contact Information to be displayed on Agent Web Site. You may list just an e-mail address or other direct contact information.

CONTACT PERSON
ADDRESS  
 
CITY STATE ZIP
PHONE FAX
WEB SITE ADDRESS E-MAIL ADDRESS

Payment Information

if paying by check or money order, please check the appropriate box and mail payment to this address:

Please write in the zip code you have selected as your territory in the memo party of your check payment.

CHOOSE ONE VISA MASTERCARD AMERICAN EXPRESS
  CHECK MONEY ORDER DISCOVER

CREDIT CARD NUMBER EXPIRATION DATE (MM/YY)
NAME ON CARD (EXACTLY AS IT APPEARS)  
 

Applicant

The Applicant warrants that the information provided is true and accurate to the best of his/her ability. Applicant further warrants to have read, understand and accepts the Internet@ Inc. Policies and Procedures and the Internet@ Inc. Agent Licensing Agreement.

I HAVE READ AND AGREE TO THE INTERNET@ AGENT POLICIES AND PROCEDURES.
I HAVE READ AND AGREE TO THE TERMS OF THE INTERNET@ AGENT LICENSING AGREEMENT.