Tom Danley's "Message of the Month"
                                                 Subscriber Application Form
               Print this application and fill in the required information. Please Print.

Name: _________________________________
Social Security or Tax ID #: __________________ (US & Canada only)
Mailing Address: ______________________________________________
City: _______________________ State: ___ Zip: __________
Country: ____________________ Email Address: ___________________
Phone #: ____________________
Sponsor Name: ______________________ Sponsor ID #: _____________
(If these fields are blank, look over the email or postcard/ad/flier for your sponsor name ID #)

The first payment is $35.00. ($25 pays for your first CD, and $10 pays for your business
start up kit, which is required if you intend to earn commissions from Tom Danley Co.)

Enclosed is a: Check ____ Money Order ___ Cash ___
***Make check or money order payable to: Tom Danley Co.***

For Credit Card payment only.

The first payment is $36.00. ($25 pays for your first CD, $1 processing fee, and $10 pays for
your business start up kit, which is required if you intend to earn commissions from Tom Danley Co.)

I would like to charge $36 one time to my: MASTERCARD ___ VISA ___
Name on Card: ______________________
Credit Card #: ______________________
Expiration Date: ______________________
Signature: ______________________________ Date: __________
Mail this completed form with enclosed payment to:
               TOP/WUL
               W261 S8300 Faulkner Rd.
               Mukwonago, WI 53149
Your application and payment will be forwarded to the
Tom Danley Co., 2850 FM 727, Jefferson, TX 75657-5734
After we position you with your Wealthy Up-line group.

If you have any questions or concerns you can contact me, Lee Taylor,
by phone at: 262-662-5109 or email your questions to: Leetopnet@aol.com