DHSC VIP and PARTNER AGREEMENT

This printable application is to be used when submitting payment by check only. Please complete, print and sign the application and mail with your check to the address listed below. If you wish to electronically upgrade your Membership go to the: Upgrade Application

Sign Me Up! Yes, sign me up as a DHS Club VIP or Partner as I have chosen below. I have read and agree to the DHS Club's Terms.

Customer Information:

First Name:
Middle Name or Initial:
Last Name:
Date of Birth:
Address:
City:
State or Province:
Postal/Zip:
Country:
Email:
Home Phone:
Fax:
Your Id:
Don't know your ID? Put your sponsor's
ID here:


Checking Information:

Name(s) on Checking Account:
Name of Bank:
Bank Routing Number:
(Reading from left to right, this should be the first
9 numbers at the bottom of your check)
Checking Account Number:
(The number to the right of the bank routing
number)
Alternate Routing Number
or Transit Code:
(Small numbers at the top of your check which
looks like a fraction, located close to your check
number  xx-xx/xx)

*** Important *** Please select the statement that applies to you, if you understand and agree.

For VIP Applicants Only. I hearby authorize DHSC, Inc. to charge the account named above $49.95 USD for my initial fee and $25.00 USD per month for my monthly fee. I understand that the monthly fee is to be charged on the first of each month, beginning with the first calendar month after my sign up. (Note: This may make your first monthly fee occur as soon as the day after your sign up, should you sign up on the last day of the month).

I also understand that DHSC's rights in each transaction shall be the same as if I had personally authorized each charge. This authority is to remain in effect until DHSC receives written notification from me of its termination, such notice NOT to occur less than 15 days prior to the due date of any given payment.

For Partner Applicants Only. I hearby authorize DHSC, Inc. to charge the account named above $34.95US for my Partner's subscription fee.

Print this form and sign here   Date: ___/____/_____

*** Important *** Signature as it appears on checking account. Print the form, then sign it, then fax or mail it to the address below.

I have read the terms of agreement and:

You must check one of the following:  I AGREEI DISAGREE


The DHS Club
2560 Placida Road
Englewood, FL 34224-5412
Fax: 1-941-475-4081

Welcome To The Club !


 

6/14/2000 GSB