Diverse Capital, Inc.
PO Box 434
Cottage Grove Minnesota 55016
  

Fax this form to

888-707-2611




CASH REWARD PROGRAM REGISTRATION FORM

Name: Home Phone: (     )
Mailing Address: Work Phone: (     )
City:                            State:            Zip: Cell / Pager: (     )
Social Security #: Email Address:

ACKNOWLEDGEMENTS

I hereby acknowledge and agree that:

  1. I am not an employee of Diverse Capital, Inc.
  2. I am responsible for any income tax liability and for notifying the IRS of my earnings
  3. If I earn $600 or more during any calendar year, Diverse Capital, Inc. will issue a 1099 IRS Form for tax purposes as required by law.
Signature
Date

Fax to 888-707-2611 or mail to
Diverse Capital, Inc.
PO Box 434
Cottage Grove Minnesota 55016