Cards for Clients Program Sign Up

1
Request Date* This field is required.
Date
Month
Day
Year
2
Agent Name* This field is required.
First Name
Last Name
3
Agent ID* This field is required.
4
Regional Sales Manager* This field is required.
Please Select
Please Select
Dulce Tee-sy
Irving Mares
Louis Valladares
Kathleen Llado-Franzke
Melissa Carrillo
Nicole Salas
Trina Townsend
Yohana Cadenas
Other
5
Email* This field is required.
example@example.com
6
Phone Number* This field is required.To personalize your cards.
Please enter a valid phone number.
7
Birthday Card Selection* This field is required.Choose your desired card.
8
Holiday Card Selection* This field is required.Choose up to 2 holidays.
9
Holiday Card Selection #1* This field is required.Choose your first holiday card.
10
Holiday Card Selection #2* This field is required.Choose your second holiday card or opt out.
11
If other, please let us know which holiday you'd like to advertise and month it should go out.We will be reviewing the requested holiday.
12
Would you like to provide your own return address to use? If you select no, we will use AGA's Anaheim office address.* This field is required.
YESNO
13
Please fill in your preferred return address.
14
Program Cost Acknowledgement* This field is required.Please review each statement by scrolling all the way down and check the box to agree to the terms & conditions.
15
Signature* This field is required.
Should be Empty: