WLLC Mail-In Application

Fill in all fields below, then click Download & Print. Mail the printed form with $159 to: Quarterly Connection, PO Box 468, Moffat, CO 81143

Note: All information must be provided in order to Download and Print.

Sponsor Information

Sponsor Name (Invited By)*

This field is required

Sponsor ID #*

This field is required

Your Information

First Name*

This field is required

Last Name*

This field is required

Your Name — how you want it to appear on your Flyer*

This is how your name will print on the flyer

This field is required

Mailing Street Address or PO Box*

This field is required

City or Town*

This field is required

State*

Required

Zip Code*

Required

Your Phone Number* (For office use only)

This field is required

Do you want your Phone Number on your Flyer?*

Yes No

Please select an option

Your Email Address* (For office use only)

This field is required

Agreement & Signature

By my Signature, I agree all sales are final and that there are Absolutely No Refunds. You agree that by "Typing your Name" it becomes your legal Signature.

Signature (Type your Name)*

Your signature (typed name) is required

Date*

This field is required

Note: After downloading, open the file in your browser and print it. Mail the printed form with $159 (Cash, Check, or Money Order) to Quarterly Connection, PO Box 468, Moffat, CO 81143.

If you would like to Mail-In your payment with your Credit/Debit Card instead of transmitting it electronically, please check this box.

Credit/Debit Card Information

Name on Card (Must be the same as Your “First and Last” Name above)*

Name on Card is required

Card Number*

Card Number is required

Expiration Date*

Expiration Date is required

CVC Number*

CVC Number is required

These fields are required only when the Credit/Debit Card mail-in payment checkbox is selected.