Liberty International Ir Confirmation Form

Liberty International New Independent Representative Sign-Up Confirmation (This form must be filled out in it’s entirety for all Fast Start Pack purchases by new Independent Representatives in order to qualify for commissions and bonuses). Please fax to Liberty International at 971-275-1876 or mail to Liberty Accounting Dept, PO Box 438, Woodburn, OR 97071

New IR’s Full Name:

____________________________________

Tracking ID Number:

____________________________________

My Sponsor’s Name:

CHICAGO VIDEO PHONES INC. – ID#96633

Application Entered By: ____________________________________

I hereby declare that I have signed up as an Independent Representative of Liberty International and have read the “Policies and Procedures” and “Terms and Conditions” which includes my responsibilities as a Liberty IR as well as Liberty International’s refund policy. My sponsor has explained the Liberty program to me, as well as worked with me to develop a “Plan of Action” of how we will work together to build my Liberty business. My sponsor has explained the monthly auto-ship program, helped me set up my own monthly auto-ship order and explained how it works, including the products/services ordered, how to make changes or cancel. I have entered my correct email address and correct Tax ID number in the system. I understand the “Terms and Conditions,” the materials regarding Liberty International’s marketing program, and the “Policies and Procedures” constitute the entire agreement between me and Liberty International. No additional promises of any kind shall be binding and enforceable unless in writing and signed by Liberty International. I give my permission for my initial order and any monthly auto-ship orders; I signed up for, to be charged to my checking and/or credit card account.

New IR Signature: ______________________________________________ Date: _________________ Revised 4-09-2008