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REGISTRATION FORM

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REGISTRATION FORM

Type of Membership*
- Bronze
- Silver
- Gold
- Platinum
- Ambassador
Full Name*
First Last
Sex*
- Male
- Female
Nationality
Family Status
- Married
- Divorced
- Other (Specify)
Occupation
Reason for Joining
Products Chosen
Email Address in Capital Letters*
Phone Number
Physical Address
Street Address City State / Province / Region ZIP / Postal Code Country
*I hereby authorize Mireille Toulekima Global Leadership to use my personal details for administrative purposes and would like to join the organization.
Date
Date Format: MM slash DD slash YYYY
Signature
Product
Price: $ 0.00
Bronze Member
Product
Price: $ 108.00
Silver Member
Product
Price: $ 208.00
Gold Member
Product
Price: $ 508.00
Platinum Member
Product (Ambassador)
Price: $ 1,500.00
Initial registration + membership
Product (included)
Price: $ 200.00
Subsequent annual subscription
Product (included)
Price: $ 400.00
Renewal of membership
Total
$ 0.00
Credit Card

American Express
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

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