Phusion Phone Enrollment – Sociallity Members

Select Action

Send Information To Lead

Name*

First Last

Email*

Desired Service*

Select Activation Fee*

Select Access*

Total Due Today

$0.00

This amount is due today, and the member's payment card will be charged $5 per month until they cancel.

Member Name*

First Last

Mailing Address*

Street Address City State ZIP Code

Email Address

Telephone Number*

Gender*

Date of Birth*

This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes.

Payment Information*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Terms and Conditions*

Customer authorizes Sociallity to charge their credit card or debit card the amount due for membership activation fee and the first month membership fee
Customer authorizes Sociallity to automatically charge their credit card or debit card the monthly membership fee until such a time that Customer elects to cancel their membership.
Customer acknowledges and understands that they may cancel the program access at any time without penalty.
Customer acknowledges, agrees to, and accepts the Sociallity Privacy Policy, the Sociallity Website Use Terms and Conditions, and the Sociallity AccessNow Terms and Conditions.
Customer acknowledges that they understand that none of the programs or services made available to them by Sociallity are Insurance products and are in no way to be considered Insurance.