Empowerism Online Business Opportunity - International Success Mentoring and Global Online Business Opportunity

Signature Required

Please click and hold your mouse inside the box and use it to sign your name. It should be the signature that is on the back of your card.

I have entered my signature above to confirm my agreement with the Empowerism terms and conditions.

Trent Brownrigg
(ID 100571)

Empowerism - International Success Mentoring and Global Business Opportunity!


	(To fax or mail your application, CLICK HERE for the PDF version.)

Note: Fields marked with an asterisk * are required


Select Services	Account Setup	Contact Details	Payment Method	Order Summary


Account Setup

	First Name*	:

	Middle Initial	:

	Last Name*	:

	Company Name (Only if you own and operate it)	:

	Show on Website	:		First/Last Name Company Name

	Make Checks Payable to	:		First/Last Name Company Name

	Format in which you want to receive Emails	:		HTML TEXT

Password* :			Verify Password* :

	Date of Birth	:		,


Contact Information

	Email Address*	:

	Street Address*	:

	Street Address (continued)	:

	City*	:

	State/Province*	:

	Region (non-U.S/Canada)	:

	ZIP/Postal Code*	:

	Country*	:

	Contact Phone*	:

Payment Method

Credit Card (all fields required):

We report all credit card fraud. The location of your computer (IP 38.107.191.95) has been logged for security purposes.

NOTES: If this is not your credit card, CLICK HERE for the correct form.
If this is a Virtual Credit Card, CLICK HERE.
If this is a DEBIT or CHECK Card, CLICK HERE.

First Name on Card:

Last Name on Card:

Credit Card # (numbers only!):

Exp. Date:

Billing Zip Code:

CC Security Code:

AlertPay Your Alerpay Email address:


	Order Summary

	Empowerism Subscription ( mos.):		$

	Hosting:		$

	Hosting Support:		$

	Do you have a coupon		Yes No



	TOTAL:		$

	Member Agreement By submitting this agreement, I certify that: (1) I will read and follow the Empowerism Zero-Tolerance Spam Policy. I understand that Zero Tolerance means my web site and any pending or future commissions will be forfeited if I violate this policy. (2) I have read and agree to abide by the Empowerism Terms and Conditions as they apply to me. (3) I understand that this signed form, along with my IP address, will be stored in a secure electronic file on the Empowerism server and will be used only in the case of a dispute. (4) I understand that any intentional misrepresentation of any information I provide on this Agreement may result in action by Empowerism, up to and including termination of this Agreement. (5) I am of legal age (the age of majority) for the state or province in which I reside. (6) I understand that I have the right to terminate my subscription at any time and, due to the consumable nature of the services, a refund is only available for cancellations made within three days of purchase. I understand that such cancellation must be in writing (by fax, postal mail, or Secure Support Ticket) and acknowledged by an Empowerism staff member to be valid. Auto-Renewal Terms By choosing Automatic Renewal, I hereby request Empowerism to charge my credit card $19.95 each month on the anniversary of my join date, starting ONE month from today, unless or until I have signed into my account and updated my preferences OR canceled my Empowerism membership. I understand that I am required to Contact Empowerism if I have a question about a charge or debit on my statement, for which I can expect a prompt resolution. Auto-Renewal Terms By choosing Automatic Renewal, I hereby request Empowerism to charge my credit card $19.95 each month on the anniversary of my join date, starting THREE months from today, unless or until I have signed into my account and updated my preferences OR canceled my Empowerism membership. I understand that I am required to contact Empowerism if I have a question about a charge or debit on my statement, for which I can expect a prompt resolution. Auto-Renewal Terms By choosing Automatic Renewal, I hereby request Empowerism to charge my credit card $19.95 each month on the anniversary of my join date, starting SIX months from today, unless or until I have signed into my account and updated my preferences OR canceled my Empowerism membership. I understand that I am required to contact Empowerism if I have a question about a charge or debit on my statement, for which I can expect a prompt resolution.