APPLIANCES 4 LESS AMERICA

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Main office:

11150 B Arrow Route
Rancho Cucamonga, CA 91739

Contact:

Class One

Exclusive Distributor

Applicant’s First Name

Last Name

Applicant’s First Name

Title (if applicable):

Phone:

Email Address:

Address

City:

State:

Zip:

Indivisual’s / Business Net Worth:

<= $300,000

>$300,000 and <=$500,000

>$500,000

How much capital do you have available to invest in this business?

<=$100,000

>$100,000 and <= $150,000

>$150,000 and <=$200,000

>$200,000 and <=$300,000

>$300,000

In which geographical areas would you like to purchase the exclusive regional distribution right? (the preferred region should not be smaller than a county)

county(s):

state(s):

At what time do you prefer us to contact you (EST)?

After getting preliminary approval, where can the applicant get initial training?

Florida

Atlanta

Chicago

Dallas

Los Angeles

New Jersey

After getting preliminary approval, when can the applicant get initial training?

within 7 days

within 30 days

after 30 days

Additional Information about the Applicant:

Please sign below to indicate that the facts you have given are accurate to the best of your knowledge and belief and may be used by A4L to verify your information and your suitability as an A4L exclusive regional distributor. You agree that omission or misrepresentation of information in this form may result in your removal from the A4L application.

Signature:

Date:

Name:

Thanks for your order!