Independent Associate Application

Attention Associates!
This completed and signed application must
be faxed or mailed to our office for you to be
qualified to receive a commission.

FILL OUT AND PRINT THIS FORM

SSN or Fed. ID# 
Your Name:
Last:             First:   Init. 
Address:        
City:              State:    Zip: 
Daytime Phone:          Evening Phone:  
E-Mail:

Sponsor's Information

Sponsor's PIN#: 25733
Sponsor's Name: Paul & Rosalie Lankow

Independent Associate Member Agreement

My signature below indicates that I have carefully read this agreement with the terms
and conditions and that I willingly accept all terms and conditions of Associate Membership
herein.

I agree and understand that I will not be eligable to participate in the compensation
plan until a completed, signed copy of this Associate Member Agreement is received
and accepted by KingsWay, either by fax or mail.

I understand that a participant in this consumer direct marketing plan has the right to
cancel at any time, regardless of the reason. Cancellation must be submitted in writing
to KingsWay at the principal address in Austin, Texas.

Signature: ______________________________________________________

OFFICE USE ONLY
Application approved by KingsWay:
By___________________________ Date___________
Assigned PIN#_____________________

1705 Capitol of Texas Highway, Suite 130, Austin, Texas 78746 (512) 306-9911 - FAX (512) 306-9922