Dear Future Business Partner, please complete the fields below so that we may consider your application to become a registered and authorized agent for Cancel-A-Mortgage. There is a one time, non-refundable $5,000.00 fee for initiating agent agreements. Once the fee is paid, we will deploy a seperate website for you to start marketing the services, and getting clients to sign up online. Please remember to tell us who referred you so that we may send that person a commission, if he/she is a registered agent. Please call us at 1-800-705-6840 should you have any questions. Thank you.<CENTER><H2>Data Entry for agent</H2></CENTER>
<FORM ACTION="/cgi-bin/webdata_pro.pl" METHOD=POST >
<INPUT TYPE=SUBMIT NAME="_cgifunction" VALUE="Add">  <INPUT TYPE=RESET VALUE="Clear form">
<TABLE BORDER=0><TR><TD><font color="orange">date added (mm/dd/yy)</font></TD>
		 <TD><INPUT TYPE=TEXT NAME="agent._timestamp" SIZE=40>
		 <font color="orange">(Use for searching only)</TD></TR>
<TR><TD><B>agent_id (leave blank):</B></TD><TD><INPUT TYPE=TEXT NAME="agent.agent_idleaveblank" SIZE="20" VALUE=""> <FONT COLOR="orange">(Auto Fill, use for searching only)</FONT></TD></TR>
<TR><TD><B>TOTAL MADE:</B></TD><TD><INPUT TYPE=TEXT NAME="agent.totalmade" SIZE="10" VALUE=""></TD></TR>
<TR><TD><B>Referred By:</B></TD><TD><INPUT TYPE=TEXT NAME="agent.referredby" SIZE="45" VALUE=""></TD></TR>
<TR><TD><B>Agent Name:</B></TD><TD><INPUT TYPE=TEXT NAME="agent.agentname" SIZE="65" VALUE=""></TD></TR>
<TR><TD><B>Email Address:</B></TD><TD><INPUT TYPE=TEXT NAME="agent.emailaddress" SIZE="65" VALUE=""></TD></TR>
<TR><TD><B>Company Name:</B></TD><TD><INPUT TYPE=TEXT NAME="agent.companyname" SIZE="65" VALUE=""></TD></TR>
<TR><TD><B>Business Address:</B></TD><TD><TEXTAREA NAME="agent.businessaddress" COLS=45 ROWS=5></TEXTAREA></TD></TR>
<TR><TD><B>Website Address:</B></TD><TD><INPUT TYPE=TEXT NAME="agent.websiteaddress" SIZE="65" VALUE=""></TD></TR>
<TR><TD><B>Date Business Started:</B></TD><TD><INPUT TYPE=TEXT NAME="agent.datebusinessstarted" SIZE="20" VALUE=""> <FONT COLOR="orange">(mm/dd/yy)
<SCRIPT SRC="/uploads/_images/cal2.js"></SCRIPT>
<IMG SRC="/uploads/_images/cal.gif" onClick="addCalendar('cal10','Select Date','agent.datebusinessstarted','0');setFormat('mm/dd/yyyy');showCal('cal10')">
                  </FONT></TD></TR>
<TR><TD><B>Describe Your Services:</B></TD><TD><TEXTAREA NAME="agent.describeyourservices" COLS=65 ROWS=20></TEXTAREA></TD></TR>
<TR><TD><B>No of Existing Clients:</B></TD><TD><INPUT TYPE=TEXT NAME="agent.noofexistingclients" SIZE="7" VALUE=""></TD></TR>
<TR><TD><B>Attorney on Staff ?:</B></TD><TD><SELECT NAME="agent.attorneyonstaff">
<OPTION></OPTION>
<OPTION>No</OPTION>
<OPTION>Yes</OPTION>
</SELECT></TD></TR>
<TR><TD><B>Number of Staff Members:</B></TD><TD><INPUT TYPE=TEXT NAME="agent.numberofstaffmembers" SIZE="7" VALUE=""></TD></TR>
<TR><TD><B>Business Proposal Comments:</B></TD><TD><TEXTAREA NAME="agent.businessproposalcomments" COLS=65 ROWS=20></TEXTAREA></TD></TR>
<TR><TD><B>How Will You Pay The Initial $5000 Agent Fee:</B></TD><TD><SELECT NAME="agent.howwillyoupaytheinitial5000agentfee">
<OPTION></OPTION>
<OPTION>Cash</OPTION>
<OPTION>Bank Wire</OPTION>
<OPTION>Check</OPTION>
</SELECT></TD></TR>
<TR><TD><B>Date You Will Make Payment:</B></TD><TD><INPUT TYPE=TEXT NAME="agent.dateyouwillmakepayment" SIZE="20" VALUE=""> <FONT COLOR="orange">(mm/dd/yy)
<SCRIPT SRC="/uploads/_images/cal2.js"></SCRIPT>
<IMG SRC="/uploads/_images/cal.gif" onClick="addCalendar('cal17','Select Date','agent.dateyouwillmakepayment','0');setFormat('mm/dd/yyyy');showCal('cal17')">
                  </FONT></TD></TR>
<TR><TD><B>What Date Will You Start ?:</B></TD><TD><INPUT TYPE=TEXT NAME="agent.whatdatewillyoustart" SIZE="10" VALUE=""></TD></TR>
<TR><TD><B>Projected Monthly Business Volume $$$:</B></TD><TD><SELECT NAME="agent.projectedmonthlybusinessvolume">
<OPTION></OPTION>
<OPTION>$5K-$10K</OPTION>
<OPTION>$11K-$25K</OPTION>
<OPTION>$26K-$50K</OPTION>
<OPTION>$51K-$75K</OPTION>
<OPTION>$76K-$100K</OPTION>
<OPTION>$500K+</OPTION>
</SELECT></TD></TR>
</TABLE>
<INPUT TYPE=HIDDEN NAME="_tableName" VALUE="agent">
<INPUT TYPE=SUBMIT NAME="_cgifunction" VALUE="Add">  <INPUT TYPE=RESET VALUE="Clear form">
<BR>
</FORM>
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