- Please fill out the following fields.
- Upon confirming all information and accepting the Licensing agreement simply click Submit.
Company Information:
* Required Fields
Business Name
*
:
Phone Number
*
:
Contact First Name
*
:
Contact Last Name
*
:
Fax Number (opt):
Address
*
:
City
*
:
Province
*
:
Postal Code
*
:
Email Address
*
:
Is franchise subject to a royalty fee?
Please Select
Yes
No
expressed as:
Please Select
Percentage
Dollar Amount
Amount:
Fiscal Start Month:
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
Agent Information:
Company Name
*
:
Business Phone
*
:
First Name
*
:
Last Name
*
:
Direct Number(opt):
Address
*
:
Cell Number(opt):
City
*
:
Province
*
:
Postal Code
*
:
Fax Number(opt):
Email Address
*
:
Assistant Name(opt):
Phone(opt):
Assistant Email: (opt):
Equifax customer number(opt):
Equifax security code(opt):
Start Date of Broker (opt):
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Eligible for volume bonus %(opt):
Please Select
Yes
No
Pro-rated volume bonus:
Please Select
Yes
No
Website Information:
Platform Basics:
Agent CRM Package
$69.95
/month
Turn key website (includes hosting - No CRM)
$24.95
/month
Pick your additional options:
Integrated calendar and task module
$9.95
/month
Turn-key agent website
$19.95
/month
Secure document storage (DocMan & PacMan)
$9.95
/month
Monthly News & Rate Advisor - Standard Package (incl. 1 campaign)
$3.95
/month
Complete Package Bundle
(all options above with Standard news and rate package)
(Savings of $13.80 per month)
$99.95
/month
Upgrades:
News and Rate Advisor: Upgrade to Premium Package
$2.00
/month
News and Rate Advisor:
Additional Campaigns(each)
$4.95
/month
News and Rate Advisor:
Additional Block(s) of 500 Recipients
$1.66
/month
Payment Schedule
Monthly
Annually
(Save an additional 10%)
Referred to GoMax Solutions by:
I understand that there is a one-time setup fee of $150.00
All information above is complete and I am ready for this application to be processed.
I have read and accept the
licensing agreement
Please add any amendments to the licensing agreement:
Please note that you must check the above boxes before this application can be submitted
Do you have any questions that I can help you with?
Choosing the right domain name?
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