Agent Name: ___________________________________________________________________

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Agent NPN: ____________________________________________________________________

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Agent Phone: __________________________________________________________________

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Agent Email: ___________________________________________________________________

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Agent Mailing Address: ___________________________________________________________

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_____________________________________________________________________________

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Total Receipts Attached: __________________________________________________________

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Reimbursement Requested: _______________________________________________________

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Infofree Subscription Payment Receipt Attached: ______________________________________

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____________________________________________________________________________
Agent Signature                                                                       Date

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** By signing this form, you agree to the terms and conditions of the program and that all marketing must be

conducted in compliance with all applicable federal and state laws. Typing your name is equivalent

to a signature. I have received pre-authorization prior to my order placement.**

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Return this request for by fax at attention: Marketing Mania 866-599-3390  or this email: jan@gordonmarketing.com