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Firm Details *

Name of Firm

street address

City

State

Zip Code

Does the firm have any other branches *

Yes

Are you independently owned *

Yes

Contact Person*

First Name

Last Name

position

Phone

Would you like to receive Emails or Calls?*

Phone

Payment Details*

the applicant below hereby agrees to provide a debit card of which the will authorize affordablefuneralsnetwork.com LLC,AFN mobile app to automaticllay debit $395.00 whenever we refer a family whose loved one is deceased and has authorized for said firm to take charge of the funeral arrangments.

the same card will be debited $145.00 when a family has expensed interset in pre-arranging a loved one with the below said firm.

card holder name

card number

expiration date

CVC number

I understand that my information will be saved to file for future transactions on my account and authorized will remain in effect until i formally request cancellation.

Thank you for your interset in becoming an affordable funerals network affiliaye. we will contact you within two busuness days.

Thank you,

Funeral Provider

Funeral Provider

Firm Details *

Does the firm have any other branches *

Are you independently owned *

Contact Person*

Would you like to receive Emails or Calls?*

Payment Details*

AffordableFuneralsNetwork.com

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