Registration for Agents, Brokers and Representatives

NYDN will appoint AGENTS to solicit and enroll Dental Plan members. Members fall into three categories:

A. Individuals and Households, including all household members, significant others, domestic employees, children away at college, etc.

B. Seniors age 60+ and all household members

C. Members of Groups including Sole-Proprietors, Corporations, LLC's, and Religious, Fraternal and Government Organizations.

Rates are UNIFORM for all members, regardless of above category. Enrollment will be single member or member + all household members, as posted on website.

As membership fees may apply to their clients, designated upon enrollment, agents
will be paid a level commission of 20% of Membership Fee paid to and collected
by NYDN, beyond the initial SIX MONTH trial period. The new member pays only
$35.00 during the SIX MONTH trial period, and this is not subject to commission.
Commissions are vested and payable for lifetime of the AGENT, and also may be
payable to AGENT's estate.

All commissions will be paid via EFT using PayPal. Agent can apply for a free and secure PayPal account if he/she does not already have one.

To register as AGENT, please complete the following:


Last Name:
First Name:
Date of birth:
Street Address
City
State
Zip
Phone	Digits only: 123 456 7890
Your Email: (This will be your AGENT ID, as well as our primary means of communication)
Re-type Email
Password
Re-type Password	(last 4 digits of SS number)
Your Paypal Email Address: (if you do not yet have a PayPal account, which we will use for paying commissions, go here: www.paypal.com to set up an account)
Will you be operating as AGENT in capacity of Business Entity or an Individual?
Name under which you are operating:
Have you ever been convicted of an crime or misdemeanor, other than a routine traffic violation?
If Yes, Please explain
Are you presently subject to any bankruptcy action or tax lien or levy?
If Yes, Please explain
Are you currently licensed by any state or government authority to practice any profession or to sell insurance or financial services?
If Yes, Please explain
Has your license to practice any profession or sell insurance or financial services even been suspended, cancelled or subject to disciplinary action by any state or government authority?
If Yes, Please explain
I have read and I accept the agent agreement and am ready to join New York Dental Network, LLC as an AGENT. Yes No