Quarterly Connection Basic Member Application

This is what the application will look like.  You can download one from the downloads tab above.  Be SURE to write in the Sponsor’s Name, Phone Number and Code.  If you do not have any sponsor information, contact us for information.  We cannot process your application without Sponsor Information.  Any applications received without Sponsor Information will be returned.


Your Name (As you want it on your Flyer)_________________________________________________


Your Legal Name (For Commission Checks) __________________________________________


Mailing Address_____________________________________________________________________


City or Town_______________________________   State ___________Zip_____________________


Phone _______-_______-_______________ Fax (Optional) _______ – _______ – ________________


Email (Please include if you have one) ___________________________________________________


Date of Birth (Must be 18 years or older) ________________________________________________


Social Security or Tax ID Number______________________________________________________


We are aware that there is a lot of fraud out there and that this is private information.  However, in order for us to “legally” pay you commissions, we MUST have this information.  If you do not wish to provide us with your number at this time, and you want to wait until we gain your trust, this is perfectly fine.  You may “skip” it for now.  But remember that we will need this information before we can pay you commissions on your sales.  All “sensitive” information is stored in our “Locked, Fireproof Vault”!  We will NEVER share your information with anyone!


By my Signature, I certify that I have read and agree to the Terms and Conditions Agreement.



 – Payment Information –

 We accept Credit Cards, Checks, Money Orders or Cash – US Dollars Only

* Note: If you are paying by Credit Card, you understand and agree that all sales are final and that you will not issue a “Charge Back” to your Credit Card Company. If you are paying by Check, you understand and agree that should your check be returned for insufficient funds, it is immediately sent to “Collections” and there will be a $25 NSF Fee. ** Note: If you must send cash, you do so at your own risk. Please wrap in dark paper for added security. Make payment to: “Quarterly Connection International”.

Total to join:  $79 Quarterly.  Please enclose $79 for your first quarterly payment.


Circle Your Payment Method:  Cash – Check – Credit Card – Money Order


_____ I enclose $79  – USA Members – * Money Order – Cashier’s Check – ** Cash- Credit Card

_____ I enclose $89  US Dollars – Canada and Mexico.

_____ I enclose $99 US Dollars – All Other Countries.

_____ Ship My Order “Priority Mail”.  I enclose an extra $5.  All Other Countries $15

CREDIT CARD INFO: (Underline One) Visa – MasterCard – Discover –  American Express

Card Number _____________________________________________Amount to Charge________________

Expiration Date __________ Security Code __________ Signature _________________________________

Mail To:  Quarterly Connection – P.O. Box 468Moffat, CO  81143


 Sponsor:                                                                                         Phone:                                                                           Sponsor Code:

 For Faster Service, you can fax your order to:  719:;655:;2633