Become a Broker | Broker Agreement

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Please complete this form, accept terms and submit online.
First Name *  
Last Name *  
Company/Group
Pay to
(for commission checks)
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Address 1 *  
Address 2
City *  
State *
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Zip Code *  
Phone *  
Phone (work)
Fax
Email Address *  
Create Password *    
Retype Password *    
URL
SS# or TIN# *  
How did you hear about us *
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Enter into the following agreement: The above mentioned individual is representing DentalSave™, and will be
paid a 35% commission on all new enrollments, with 35% paid on renewals automatically. These commissions
will be paid to the representative within 30 days upon receipt of enrollment by DentalSave™.
Upon receipt, you will receive a starter kit to begin enrolling clients. Please press submit only once.
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