Representative Enrollment

Become a representative today! If you wish to sell the finest prescription program on the internet, please fill out this form to immediately become a representative with MEDPro.

Personal Information
Salutation:
First Name:
Middle Initial:
Last Name:
Social Security Number:	--
Date of Birth::	,
E-mail:
Business Information
Company:
Select Tax Type:	Individual/Sole Proprietor Corporation Partnership
Employer Identification Number:
Business Address:
Business Address 2:
City:
State:
Zip:
Business Phone:	--
Business Mobile:	--
Business Fax:	--
Resident Information
Resident Address:
Resident Address 2:
Resident City:
Resident State:
Resident Zip:
Resident Home Phone:	--
Manager Information
Manager Name:	Place your manager's first and last name in box.
Primary mailing address to receive Company Information:	Business Address Residence Address
Account Information
Password:	(6 or more characters) This will be used to log into your back office.
Commission Information
Commission Code:	Contact your upline manager for commission code.
Financial Institution:
Account Type:	Checking Savings
Routing Number:
Account Number:

By initialing here I represent and acknowledge the following:

I have never been convicted of a felony.
I agree to abide by all written rules and regulations (subject to change at any time) set forth by the Company.
FAIR CREDIT REPORTING ACT PRE-NOTIFICATION This is to inform you that as part of our procedure for processing your application, an investigative report may be made whereby information is obtained through credit reporting agencies and personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics, and mode of living, whichever may be applicable. You have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

By initialing here I have read and acknowledge the terms and conditions of the Representative Contract

By initialing here I have read and acknowledge Parts I & II of the Form W-9