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“JUST FOR ME” – LIFETIME MEMBERSHIP REFERRALS

Referral Applicant # 1

Name: __________________________________________________

Address: ________________________________________________

City: __________________ State: ___________ Zip _____________

Social Security ______ – ______ – _______ DOB _____/___/_______

Home Tele:      (____) ______________ Cellular: (____) ___________

Email Address: ___________________________________________

Referral Applicant # 2

Name: __________________________________________________

Address: ________________________________________________

City: _______________________ State: ___________ Zip _________

Social Security ______ – ______ – ________ DOB _____/___/______

Home Tele:      (____) ______________ Cellular: (____) ___________

Email Address: ___________________________________________

Referral Applicant # 3

Name: __________________________________________________

Address: ________________________________________________

City: _______________________ State: ___________ Zip _________

Social Security ______ – ______ – ________ DOB _____/___/______

Home Tele:      (____) ______________ Cellular: (____) ___________

Email Address: ___________________________________________

Referral Applicant # 4

Name: __________________________________________________

Address: ________________________________________________

City: _______________________ State: ___________ Zip _________

Social Security ______ – ______ – ________ DOB _____/___/______

Home Tele:      (____) ______________ Cellular: (____) ___________

Email Address: ___________________________________________

  • MAIL REFERRAL LIST TO THE ABOVE ADDRESS WITHIN THIRTY (30) DAYS.
  • REFERRALS CAN OBTAIN AN APPLICATION FOR COMPLETION BY VISITING WEBSITE: axxess2020.com
  • FULL PAYMENT OF $ 100.00, PAYABLE TO AXXESS 2020 LLC MUST BE ENCLOSED WITH APPLICATION FOR PROCESSING.
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