Thank you for taking the time to fill out the following information and confirm your membership for 2017.

Please select the Circle you belong to, the Facilitator of that Circle is in ( ).
Member Name *
Member Name
Mobile Phone
Mobile Phone
Office Phone
Office Phone
http://
Birthday
Birthday
Year not required.
Business Address
Business Address
INVOICING INFORMATION
Please provide the following information for invoicing purposes.
Please select your payment plan:
Please note that you will be committing to one year of membership. All invoices will be due 30 days from the date of issue.
If you require a different payment plan, need to ask for a different payment option than check or credit card, please let us know.
Remit invoice to:
If the invoice is to be sent to someone other than the member, please provice the folliwng information.
Name
Name
Phone Number
Phone Number

If you have any questions, please contact Lani Basa at 952-905-9442.