Name *

First Name

Last Name

Phone *

(###)

###

####

DOB *

MM

DD

YYYY

Company Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Membership Options *

Option 1. 6 month membership payment of $348.50+GST ($400.78 inc GST) Membership fee is paid on acceptance of your application. Due every 6 months. You are required to attend on a weekly basis. An invoice will be emailed out on acceptance. This payment is non-refundable should you leave the group for any reason. Option 2. Monthly payments of $65+GST ($74.75 inc GST) Paid on acceptance of your application. You are required to attend on a weekly basis. We recommend you commit to this as you are liable to pay the required amount each month, regardless of your attendance. You are committed to a term of 6 months. All payments are non-refundable.

Option 1 - Annual

Option 2 - Monthly

Agreement

By submitting this request for enrollment, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a member, any false statements, omissions or other misrepresentations made by me on this request for enrolment form may result in my expulsion from Synergy Networking. By clicking and submitting this agreement you agree to all our terms and conditions.

I agree to all terms and conditions