BETA SOURCE, INC.
& Worldwide Universal Health Network, Inc.
Independent Representative Application and Agreement
160 Whiteford Way
Lexington, SC 29072
Toll-Free Fax Orderline: 1.888.957.0351
Telephone: 803.957.0350
NOTE: Items marked with ** are mandatory entry fields.
**First name
Middle initial
**Last name
SS # or Fed ID #
**Street address
**City
**State
**Zip Code
Country
**Home Phone
Fax number
**
Email address
Create your BetaExpress Password
I agree to become familiar with and abide by all rules and regulations of
BetaExpress.com and understand that any falsification or deliberate omission
on this application is sufficient reason for refusal of application.
Today's Date:
The person who sent you to our website should have given you a reference number. Their sponsor ID #. Key their information below. If you don't know who, we will track who's page you came from and give appropriate credit
Sponor IR. ID. #
Sponsor Name