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Empower Network Credit Card Authorization Form PLEASE PRINT AND COMPLETE THIS AUTHORIZATION FORM TO RETURN TO EMPOWER NETWORK LLC. 00 for the Empower Network Total Transformation Exclusive Training Event. By signing this form you acknowledge that there are no refunds issued for this purchase. 00 to the above listed credit card ending in for purchase of the Empower Network Total Transformation Exclusive Training Event. Signature of Cardholder Print Name of Cardholder Date Purchase Agreement By signing this form you acknowledge that your card will be charged a one-time purchase of 12 500. All information will remain confidential* Name on Empower Account Email Cardholder Name Billing Address for Credit Card City Country State/Province Zip/Postal Code Credit Card Number Credit Card Type Expiration Date CVV 3 / 4 digit code I authorize Empower Network to charge the full amount of 12 500. 00 to the above listed credit card ending in for purchase of the Empower Network Total Transformation Exclusive Training Event. Signature of Cardholder Print Name of Cardholder Date Purchase Agreement By signing this form you acknowledge that your card will be charged a one-time purchase of 12 500. In addition you understand that you are buying a ticket to an Exclusive Training Event hosted by Empower Network located in the Dominican Republic teaching high level concepts to build ANY marketing business. Although these strategies have worked for others no one can guarantee income or results of any kind* Success comes from hard work perseverance leadership and strategy. Refer to our full earnings disclosure for daily updated average earnings at http // http //www. empowernetwork. com/income Please Return Document To EMAIL TotalTransformation EmpowerNetwork. com FAX 888 204 - 1266. All information will remain confidential* Name on Empower Account Email Cardholder Name Billing Address for Credit Card City Country State/Province Zip/Postal Code Credit Card Number Credit Card Type Expiration Date CVV 3 / 4 digit code I authorize Empower Network to charge the full amount of 12 500. 00 to the above listed credit card ending in for purchase of the Empower Network Total Transformation Exclusive Training Event. In addition you understand that you are buying a ticket to an Exclusive Training Event hosted by Empower Network located in the Dominican Republic teaching high level concepts to build ANY marketing business. Although these strategies have worked for others no one can guarantee income or results of any kind* Success comes from hard work perseverance leadership and strategy. Although these strategies have worked for others no one can guarantee income or results of any kind* Success comes from hard work perseverance leadership and strategy. Refer to our full earnings disclosure for daily updated average earnings at http // http //www. empowernetwork. Refer to our full earnings disclosure for daily updated average earnings at http // http //www. empowernetwork. com/income Please Return Document To EMAIL TotalTransformation EmpowerNetwork. com FAX 888 204 - 1266.

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