MW Associate Upgrade Application

M. WORSLEY
International Consultants
'We try Never to say No!'

Unit 1, 9 River Coast Road, Werribee South VIC 3030, Australia Phone: +61-3-9742.1894 Fax: +61-3-9742.1463
Email: mworsley@mworsley.com Internet WEB Site: http://www.mworsley.com

Application for Upgrade to Associate

(International Division)

Name:

Ref #

Contact Address:

Phone: +

Email:

Fax: +

Mobile:+

Bank for Deposits:

Bank Address:

Account Name:

Currency:

Account Number:

Credit Card for Fees: (we accept Visa/Mastercard/Amex/Diners)

Card Number:

[Amex ID: ]

Cardholder's Name:

Expires: /

I/We hereby apply to upgrade to Associate grade with M. WORSLEY and confirm that the above details are correct. I/We understand that this reclassification involves an ongoing commitment to engaging in a minimim level of network promotional activity or the payment of a monthly fee to cover the shortfall as outlined on the M. WORSLEY website at http://www.mworsley.com/ and clicking on the Networking link.

Signed:

Dated: / /

Please print out and after completing fax this form to us at +61-3-9742.1463 for processing.

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