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MEMBERSHIP APPLICATION FORM

ROMANIA
CUSTOMER INFORMATION
Full Name (Last, First, Middle) Date of Birth (DD/MM/YY) (must be at least 18)
LAST FIRST MI.

Billing Address (NO P.O. Box)

City State ZIP

Mailing Address (If Different From Billing Address)

City State ZIP

Home Mobile Email (Required)

PRODUCT SELECTION

DreamTrips Gold Membership: $199.99 (Initial Membership Fee) + $49.98/month (Monthly Membership Fee)
DreamTrips Platinum Membership: $299.99 (Initial Membership Fee) + $99.99/month* (Monthly Membership Fee)

* Monthly Membership Fees are automatically charged to payment information on file. First months Fees are charged at the time
of purchase. Members may change payment information on file at any time.

**Please Choose ONE Form of Payment.

PAYMENT

IPAYOUT/EWALLET: You will receive an email to activate and fund your iPayout/eWallet account and complete your
enrollment. This will be a contractual relationship directly between you and iPayout/eWallet and
is subject to applicable fees and their separate terms and conditions provided during the sign up
process.

CREDIT CARD: CARD TYPE MASTERCARD VISA AMEX

Name on Card Credit Card #

Expiration Date 3- or 4-Digit Security Code Billing address


MM/YY

City State ZIP

WORLDVENTURES MARKETING S.R.L.


Bucharest, 5th District, 22 Tudor Vladimirescu Boulevard, Green Gate Office Building, 5th floor, Office 513, Romania
PH : 40376300045 FAX 40(0)317107181 WWW.WORLDVENTURES.COM

Revised January 16, 2017

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