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Activate Your Position in the Matrix Today!

Return to: DBN P.O. Box 8147 HuntsviUe, TX 77340 Phone: 1-866-722-5363 ext 2 (FAX) 1-866-722-5363
Please Print! No Doctor writing please Take Your Time make sure everything is complete Name: Address: SSN/Fed Tax 1D#: Phone: (required)

DBN ID#:

Email address:

Enroll Me as A Subscriber. I am of legal age for the state in which 1 reside.

Check 4 appropriate Monthly Product box -I Subscription


130 Opportunity Seeker Leads 160 Opportunity Seeker Leads [120 Opportunity Seeker Leads

Suggested Retail
$ 60.00

Subscription Cost $30.00 $50,00 $100.00

Quantity Shipping

SUB Total
$35 $55

$5 $5 $5

$120.00
$240.00

$105

Payment Type:

**Check (U.S.)

Money Order

Cash (required fee for bill reminder service)

$3.00

"All Texas Residents MUST Add 8.25% Sales tax : $


Payment Type: _Visa Master Card Discover (no bill reminder fee for credit cards)

Grand Total $
Cardholder: Expiration: Security Code: Signature: Acct/ Card #:

YES I Enroll Me In Your "AUTO-SHIP" Program. I hereby authorize CXC to charge on a monthly basis the Credit or Debit card account submitted by me for payment for this order. This authorization may be cancelled at any time by submitting written notice at least ten (10) days before the next processing date for your shipment. I also agree not to stop payment or charge back my product order(s).

Signature: Date: By being an auto ship you insure you won't lose any commissions due and you receive leads in a timely manner.
This "Auto-Ship Authorization" MUST BE DATED AND SIGNED In Order To Be Processed.

VERY IMPORTANT!! Make Checks Payable to CommissionXchange and Note That The Charge On Your Credit Card Will Show As CommissionXchange or CXC!!

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