Taitam Verification

Phone#, email, LName, Acc#, Mem#

Sales Office: — Choose Sales Office — ACE_BPO CITY_BPO

Deal Status: — Choose Deal Status — Sale Pending Call_Back Hang_Up Disconnect

Sales Agent: *

Sale Date: *

Account#:

Admin Fees Paid: — Choose Fees Paid — Yes No

Cert Sent: — Choose Cert Sent — Yes No

Portal Sent: — Choose Portal Sent — Yes No

Welcome Call: — Choose Welcome Call — Yes No

Member ID:

First Name: *

Last Name: *

Home Phone: *

Cell Phone:

Address: *

City:

Province:

Postal Code:

E-mail: *

A) Which of the following Gift Select?: — Choose a Gift — 4 NIGHT TRIP TO LAS VEGAS 7-NIGHT LUXURY RESORT GETAWAY GETAWAY 4 NIGHT LUXURY CRUISE GETAWAY

B) Bonus Gift Select?: — Choose a Gift — 4 NIGHT LUXURY CRUISE 7 NIGHTS RESORT GETAWAY FAMILY OF FOUR $300 RESTAURANT CASH PREMIUM QUALITY TRUE WIRELESS EARBUDS

C) Cutomer Understand they Have to Pay Activation FEE $299.95?: — Choose Activation_fee — Yes No

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