Membership Application Form


A program by Ann Farrell, The Corporate Success Coach
Home \| YCS Member Forum \| Corporate Coach Forum \| Tell a Friend \| Text Size \| Search \| Member Area

home | Membership Application Form

Secure Subscription Form

We respect your privacy. The personal information requested below is for use in processing your credit card, which is done with secure encryption. We never reveal, share, or sell member information. For complete details see our Privacy Statement.

Customer Information

* = Required - Must match credit card billing address!

First Name [ required ]
Last Name [ required ]
Company
Address Line 1[ required ]
Address Line 2
City [ required ]
State [ US & Canada ]
State/Province [ All other Countries ]
Zip/Postal Code [ required ]
Country [ required ]
Your E-mail Address [ required ]
Phone or Fax Number [ required ]

Shipping Information

Shipping same as billing address

Ship To First Name [ required ]
Ship To Last Name [ required ]
Ship to Company
Ship to Address Line 1[ required ]
Ship to Address Line 2
Ship to City [ required ]
Ship to State [ US & Canada ]
Ship to State/Province [ All other Countries ]
Zip/Postal Code [ required ]
Ship to Country [ required ]

Subscription Options

Subscription Plan:	Quantum Endeavors Licensee ($29.00 per month) Your credit card will be charged monthly. You may cancel at any time after 12 months. Your Corporate Success - Charter Membership($30.00 per month) Your credit card will be charged monthly. You may cancel at any time. Your Success Membership ($47.00 per month) Your credit card will be charged monthly. You may cancel at any time at Your Account. Your Success Premium Membership includes One-on-one Coaching (credit for 20 minutes earned each month) ($99.00 per month) Your credit card will be charged monthly. You may cancel at any time at Your Account. Coaching for Corporate Business Building Program ($197.00 per month) 12 month commitment required. Your credit card will be charged monthly. Coaching for Corporate Certification Program ($500.00 per month) 12 month commitment required. Your credit card will be charged monthly. One-on-one Monthly Coaching Clients ($500.00 per month) Your credit card will be charged monthly. You may cancel at any time with 30 days notice at Your Account. SOAR to Success Six-month Leadership Progam ($49.00 per month) Your credit card will be charged monthly. Requires 6 month payment commitment.

Choose LOGIN Name [ required ]

Choose PASSWORD [ required ]at least six characters long, using alphas and numbers, no spaces.

Confirm PASSWORD [ required ]

Payment Information

Payment Method [ required ]
Credit Card Number [ required ]
Credit Card Security Code [ required on (MC/Visa/AMEX) ? ]
Expiration Date [ required ]	/
Name on Credit Card [ required ]
Are you Renewing?(not a new membership)
Do you wish to receive email alerts?
<<< Please Check The Box to acknowledge that you have read and understood our terms of use.


NOTE: It can take up to a minute to process the credit card information and obtain approval. Please do not press the submit button multiple times - doing so could cause double billing.
For the protection and privacy of our visitors and customers, as well as the security of the server, suspicious activities on our site are monitored, tracked and reported.