Copyright© 2017 Flat Rate Leads
Legal Disclaimer: Your access to and use of this web site is subject to additional Terms and Conditions. See ( Terms and Conditions )

Please Print, Fill Out Form Below And Fax Back To Our Office At 313-355-9044 Thank You

Customer Name: ____________________________
Billing Contact: _____________________________
Billing Address: _____________________________
City: _______________________State_____________
Zip or Postal Code:____________________________
Billing Phone Number: (___)_____________________
Billing Fax Number: (____)______________________
Alt Address __________________________________

Flat Rate Leads Sales Representative:

Bill Turner Billing E-Mail: Telephone 1-888-610-4313

Marketing Services Fees Summary

Monthly Commitment: $
19 / Month
Referral Service Rates: Please select which type leads are requesting below
_____Email Leads $5 Per Lead Generated
_____Live Call Leads $10 Per Lead Generated
Payment Due On 23th of Each Month
Cancel At Any Time With Written Notice (7) Days Before Renew Date
One-Time Platform Access Set-Up Fee: WAIVED

Please place a check mark by the type leads your requesting:

Additional Terms:

Service Term: The initial Service Term of the Agreement is (30) Days This Agreement Renew Every 23rd Day of Each Month. Customer May Cancel At Any Time, Must have Written Cancellation Notice (7) days before Renew Date

This Services Agreement ("Agreement") is entered into on this ______ day of _____________, 2017, (the "Effective Date") between ________________________________. With its principle place of business __________________________________________ Flat Rate Leads and the Customer listed above ("Customer"). This Agreement includes and incorporates the above Order Form, as well as
the Terms and Conditions set forth at the following URL FlatRateLeadstermsandconditions (or such successor URL designated by Flat Rate Leads):

(X) Title: Manager Flat Rate Leads

By (Signature): ________________________________ Date ________________

(X) Title: Customer: (Print Name______________________________________

By: (Signature): _______________________________ Date________________

Credit Card Authorization

The undersigned hereby authorizes Flat Rate Leads, to charge the credit card indicated below. Monthly Invoice will be charged automatically at the beginning of the following month.

Customer ID# _________ (For Internal Purposes Only)
Name of Cardholder: ______________________________________
Name of Business:________________________________________
Billing Address: __________________________________________
Phone number: (____ )_____________________________________
E-mail address:___________________________________________
Card type (circle one) Visa MC AMEX
Credit Card number:
(3-digit code imprinted on signature strip after the credit card number for Visa and MasterCard. This is a 4-digit code on the front of Amex cards)
Expiration date:
Authorized Signature:_________________________________________

Please Fax Completed Authorization Form to:
Flat Rate Leads
Fax to: 313-355-9044
Office 1-888-610-4313

Marketing Agreement and Credit Card Authorization Form

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