WCM777 MEMBERSHIP REGISTRATION FORM

(Please Print)

SPONSOR INFORMATION (SPONSOR FILLS THIS AREA)

Today’s date:

Sponsor Name:

Sponsor User Name:

Placement User Name:

Placement: Left Right Auto

NEW MEMBER INFORMATION

Member’s Name: Member’s User Name:

Home Phone No.: ( )

Mobile Phone No.: Birth Date: Age: Sex:

( ) / / M F

Mailing Address: ID Number: Email:

P.O. Box: City: State: ZIP Code:

Billing Address (if different from Mailing): City: State:

ZIP Code:

Distributor Type: Individual Company (Corporation, LLC, etc.):

Notes:

The above information is true to the best of my knowledge. I have fully understood and agree with the corporate policy, marketing plan, and the privacy policy of WCM777.

Applicant Signature: ________________________________________ Date: _________________

PAYMENT METHOD

(Please give a clean copy of Deposit / Wire Transfer receipt to your Sponsor for Registration.)

Method of Payment: Cash Bank Branch Deposit Wire Transfer Cashier’s Check

Payment Amount: Number of Units: