Partner Enrollment – Sociallity Members

Program Selection*

Deployment Selection*

Desired Referral Code*

Monthly Maintenance*

Price: $5.00

Monthly Maintenance*

Price: $20.00

Monthly Maintenance*

Price: $50.00

Monthly Benefit Access Fee*

Price: $20.00

Total Due Today

$0.00

Payment Authorization

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Name One Card*

First Last

Mailing Address*

Street Address City State ZIP Code

Telephone Number*

Your mobile phone number become your Sociallity Benefit Member Number.

Email Address*

User Name*

Password*

Enter Password Confirm Password

Referral Code

*

I hereby authorize Sociallity Benefits to charge my credit card or debit card the amount due for this benefit activation
II hereby authorize Sociallity Benefits to automatically charge my credit card or debit card the monthly benefit access fees. I understand that this charge will automatically be made until such a time that I elect to cancel my active benefit(s).
I hereby acknowledge, agree to, and accept the Sociallity Privacy Policy, the Sociallity Website Use Terms and Conditions, the Sociallity Benefits Terms and Conditions, and the Sociallity Healthcare Coin Terms and Conditions.
I hereby agree to the terms and conditions of the Sociallity Tiered Marketing Partner Agreement.

*

I hereby authorize Sociallity Benefits to charge my credit card or debit card the amount due for this benefit activation
II hereby authorize Sociallity Benefits to automatically charge my credit card or debit card the monthly benefit access fees. I understand that this charge will automatically be made until such a time that I elect to cancel my active benefit(s).
I hereby acknowledge, agree to, and accept the Sociallity Privacy Policy, the Sociallity Website Use Terms and Conditions, the Sociallity Benefits Terms and Conditions, and the Sociallity Healthcare Coin Terms and Conditions.
I hereby agree to the terms and conditions of the Sociallity Marketing Partner Agreement.