Welcome to VALIS International !

Personal Account, US Address,
and Affiliate Program Order Form

Choose your Program

GOLD: 1st Class US Address + Personal Account with affiliate program ($300 +$100 postage deposit + $100 opening bank deposit) US Office Address for 1st Class flat mail forwarding -- $300/year to maintain + Postage

SILVER: Personal Account w/ affiliate program ($100 + $100 opening bank deposit) No US Address supplied -- One Time Setup Payment Only

BRONZE: Affiliate Program registration -- $50 -- a SILVER Personal account with $100 in it will be opened when you have referred 6 affiliates/clients (You can upgrade to Gold anytime)

How you found us:

A. Who You Are

Full Name:
e-mail address (no free email providers, like hotmail or mail.ru etc.):
Your Site:
First Name:
Middle Initial:
Last Name:
Phone number:
FAX:
Date of Birth:	(11-Oct-71)
Passport #:
Home address
Suite / Apartment #:
Street:
City:
Province / State:
Postal Code:
Country:

B. Business Forwarding Address
mail will be forwarded to you @

Suite / Apartment #:
Street:
City:
Province / State:
Postal Code:
Country:
Print Address Exactly How it Should Appear On an Envelope Addressed to You (First Line must be Name -- Last Line must be Country):
ADDRESS LABEL