***** IMPORTANT NOTICES! *****
To submit this form your client's funding requests for the first Ninety (90) Days of your Trial Period MUST NOT BE HIGHER THAN $30,000 for any qualifying application submitted to this agency.  If your funding requests are higher, you will need to register in our Annual Broker Program and pay all participation and buy-in fees associated with this program.

If you are a business applicant applying as a Broker, all information regarding the Owner of your Company, Corporation, and/or entity is required to process this request.  Please DO NOT leave spaces blank below or your application will be denied.

To register in our Broker's Program on a Ninety (90) Day Trial, please complete the form below and return. 
Complete and fax back to: 1-866-RTISTIC! (1-866-784-7842) for immediate consideration.  If you are a strong candidate, your Broker's Introduction and Startup Packet will arrive within 2-3 business days.  If your application is not accepted for any reason, we will provide you with the reason(s) for denial in writing. 

Thank you for considering our agency, and our unique Broker Programs!!

 

O N L I N E   B R O K E R   R E G I S T R A T I O N   F O R M
  ►  Email to: registrations@artistic-capitalcorp.com  ► 
Fax to: 1-866-RTISTIC! (1-866-784-7842) 24 hours per day, 7 days per week.

Today's Date:            $460.00 processing fee required
                                                                to setup temporary Broker Account. *

 * Processing Fee required for all applicants.  ($375.00 account setup + $85.00 credit report fee)

Bold = Required   (All fields are required to submit this application.)
Italic = Required
Referring Broker: (If any)
Referring Broker Email:
Referral Website:
Referral Phone: (incl. area code)
How did you hear about this offer?: (Required)
Registering Broker: Commission Payout Information:
First Name:
Last Name:
Social Security #:
Date of Birth:
Mother's Maiden
Name:
Email Address:
Phone Number:
Fax Number:
Company Name:
Phone Number:
Address:
City:
State/Province:
Other State/Province:
Zip/Postal Code:
Country:
PAYEE First Name:
PAYEE Last Name:
Email Address:
Phone Number:
Cellphone Number:
Fax Number:
PAYEE Company:
EMPL. ID #:
DUNS #:
Incorporated? (Yes/No)
Provide Date as 03/02:
Address:
City:
State/Province:
Other State/Province:
Zip/Postal Code:
Country:
Personal Information: First Client Funding Information:
Marital Status:
Type of Funding
Experience:
Reference Name:
Reference Relation:
Reference Phone #:
Driver's License #:
Driver's Expiration:
Backup Phone #:
Backup Fax Number:
Business EIN Number:
2nd Mailing Address:
City:
State/Province:
Other State/Province:
Zip/Postal Code:
Country:
Your Client's Name:
Last Name:
Social Security #:
Date of Birth:
Driver's License #:
Driver's Expiration:
Email Address:
Phone Number:
Business Name:
Business EIN #:
Address:
City:
State/Province:
Other State/Province:
Zip/Postal Code:
Amount Requested:
Country:
BROKER AGREEMENT & CERTIFICATION  

Applicant agrees:
1.  I will not be considered an employee of Artistic! Capital Corporation, its subsidiaries, and/or other company's owned or operated by this agency and will act an Independent Contractor to this agency when considering and submitting this form.

2.  I understand that my temporary association with Artistic! Capital Corporation is for a period of Ninety (90) Days only and will terminate at that time should I not provide agency with suitable and/or verifiable leads that can be funded.  I understand that I may consider accepting a long term relationship should it be offered to me by Artistic! Capital Corporation upon my Ninety (90) Day Trial Period.

3.  I understand that submitting this request to Artistic! Capital Corporation that I will be paid at Two Percent (2%) of the total amount paid to Artistic! Capital Corporation on each funding referral that is approved and funded through this agency.  I understand that in order to earn higher commissions that I must register in Artistic!'s Annual Broker's Program which is available to me at anytime during my Ninety (90) Day Trial Period.

4.  I understand that in order to participate in any buy-in level offered through Artistic!'s Annual Broker's Program that I must pay the annual participation fee and complete a Broker's Registration Application for processing and return my accompanying payment for these services in order to activate a Broker Account.

5.  I understand that I will be paid within 24-48 hours from the date a funded transaction is approved for any of the clients, referrals, or customers in which I have submitted to Artistic! Capital Corporation; and have been notified of their approvals.

6.  I will email or fax this form with my electronic signature if by email, serving as my original.  If faxing, I will provide my signature below where applicable and return to: 1-866-RTISTIC! (1-866-784-7842) 24 hours per day, 7 days per week with a copy of my payment check, cashier's check, money order, online bill confirmation and/or my credit card to be charged for my processing fees and temporary account setup.  I understand that I will be notified at the email address or fax number provided upon my acceptance.

7.  I understand that I will not refer a Broker's Agreement until I have successfully registered in one of Artistic!'s annual participation buy-in levels required for execution of this request on a full-time basis.  I understand that all payments, proceeds, earnings, and/or income received through this agency during my first Ninety (90) Days Trial Period are my responsibility to report to appropriate parties at year-end.  I understand that agency will provide to me a 1099 during the tax year in which I earned any income, profits, and/or rewards by utilizing this service and programs.

8.  I confirm that I am the individual in the Registering Broker section of this request form and that I have not provided any falsified information to this agency to ensure an approval of acceptance.  I certify that the social security number and tax reporting information provided belong to me as I presently use when reporting my own personal or business tax returns.  I confirm and attest that I have not used the information of anyone to request this service, and I agree to abide and uphold the terms and conditions as outlined and agree willfully to adhere to the guidelines as presented to me.

9.  I understand that my electronic signature below shall serve as my original signature when submitted.  If providing my electronic signature I shall return this request form by email as instructed below.  If I am faxing my signature, I have provided my original signature to Artistic! Capital Corporation in acceptance of my request, and have dated it accordingly.

10.  The date provided by me below confirms that Ninety (90) Days after this day shall be my entire Trial Period, and should I wish to continue referring my leads, clients, and/or operating as a Broker; I agree to register and/or signup in one of Artistic!'s Annual Participation buy-in levels in order to continue my association with this agency.  Upon my Trial Period ending, I understand that I will have only Seventy-Two (72) hours from the expiration of my Trial Period Date to execute my annual participation payment to Artistic! Capital Corporation, and have made my buy-in level payment.  If I have not complied within Seventy-Two (72) hours I understand that my temporary broker account shall immediately be terminated and any and/or all marketing literature provided to me must be therefore returned to this agency upon my termination.

Electronic Signature (Type your name in all capital letters.)

Broker Signature:      
Date Signed:


FAXED SIGNATURE (REQUIRED)

X _________________________________________

Date Signed:  _______________________
 

Payment Information: (Must be provided or your request will not be processed.)
Online Billing:   (Provide your email address.)
Credit Card No.: (Visa, Mastercard, AMEX, Discover & Debit.)
Credit Card Exp. Date: (Ex. Mo/Year)
Name on Credit Card: (Type exactly as it appears on credit card.)
Billing Address: (Must match bank records.)
City, State, Zip Code:
CVV / AVS #: (3-digits on back V/MC) (4-digits on front if AMEX.)
Checking Acct. #: (Fax voided check with this request.)
Bank ABA Routing #: (9-digits at left of check.)
Bank Name on Check: (Must match faxed check to process.)
Amount Authorized: ($460.00 Due at time of submittal.) *

* All online payment transactions are charged an additional $15.00 surcharge for processing.
* Your credit card statement will show a charge to:  ARTONL

Note:  We reserve the right to charge a $100.00 returned check fee on all submitted personal or business checks that are returned insufficient, account closed, funds not available, refer to maker, insufficient funds, and/or any other return check notification received by your financial institution.  Any credit card disputed or charged back to this agency after submitting will be charged a $250.00 charge back fee for each occurrence.  If you are unsure of your balances available, please do not submit this form for processing.

RETURN INSTRUCTIONS:
Email - return to: registrations@artistic-capitalcorp.com
By Fax: 1-866-RTISTIC! (1-866-784-7842) with your payment
check, made out to Artistic! Capital Corporation for the total
amount due.
Online Billing: billme@artistic-capitalcorp.com
PayPal: send payment to the following email address with
$15.00 online fee to artisticapital.corporateoffices@verizon.net
 


©2000-2003 Artistic! Capital Corporation; ALL RIGHTS RESERVED.