Independent Agent Agreement

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Financial Education Services

Name

Cornelius Burks

Title

FES Agent

Email

marketingmy360@gmail.com

Call

(562) 972-6701

1. Enrollment Information

First Name*

Middle Initial

Last Name*

Company Name*

Fed Tax ID*

Birth Date*

Title*

Gender*

Address*

Apt / Suite

City*

State*

Zip Code*

Email*

Verify Email*

Cell Phone*

Alt. Phone

2. Select Membership Type

FES Protection Plan Membership

Agent: $199 + FESPP: $89/Month

Total: $288

Standard Agent

One Time Fee

$199

Standard Agent

One Time Fee

$249

SSN*

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3. Terms & Conditions

I consent to the use of electronic records and have read, understand and agree to the Financial Education Services/YFL IR Agreement Policies and Procedures

Independent Agent Acceptance of the Agreement (Click here for details)

FES Protection Plan Terms and Conditions of Enrollment (Click here for details)

4. Password Selection

Password*

Conf. Password*

5. Commision

I would like to receive my commission on check

I understand that a $4.00 processing fee will be taken out of each weekly commission payment.*

Deposit my commssion to my Personal Checking/Saving Account.

I authorise Financial Educational Services to electronically deposit my commission to the specified account.
I understand that a $4.00 processing fee will be taken out of each weekly commission payment.*

Direct Deposit Information

Bank Name*

Acc. Holder Name*

Account Type

Checking Saving

Account #*

Routing #*

6. Payment Information

Payment Type*

Card Type*

Card Number*

Show

Exp Date*

CVV Code*

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Billing Address Is Same As Above

Card First Name*

Card Last Name*

Billing Address*

City*

State*

Zip Code*

Pref. language*

English Spanish

Agent Name*

Agent ID*

Address Verification

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