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Certified Travel Network, Inc.
HOME of BUSINESS BASED TRAVEL Affiliate Application

Name:
Address:
City:
eMail:

SSN #:
Telephone #:
State and ZIP:
FAX #:

Intended Travel Agency Name
Cannot include the word Certified

Complete Following if Business Based

Business Name:
Owner's Name:
Street Address:
City:
State and Zip:
Telephone #:
FAX #:
eMail Address:

Social Security # or Federal Tax ID Number:
Business Form:	Corporate Partnership Individual
Type of Business
Describe Location of Your Business :
Distance to nearest travel ageny:
Who will operate your travel agency?

Payment Information

Form of Payment:

Credit Card Number:

Expiration Date (MM/YYYY)

Card Owner Name as it Appears on Card:

Card Billing Address:
City: State: ZIP:
Last 3 digits on Back of Card in Signature Strip:
You must attach copy of front and back of Credit Card
You must attach copy of valid state drivers license

Signature of Card Holder:________________________________________Date:___________________

I apply to become an Independent Associate of Certified Travel Network, Inc. I agree to pay to Certified Travel Network, Inc. a one-time fee of $499, a $18 per month service fee. I understand that all commissions, base, override and bonus will be split 50/50.

Signature of Applicant:______________________________________________ Date:____________________________________
After completing this form, print Application and Agreement, sign both and mail to:
Certified Travel Network, Inc., 6444 NW Expressway, Suite 808, Oklahoma City, OK 73132

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