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Pivotal Wealth Agent Registration
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Middle Name:
Last Name: *
Date of Birth: *
ex. MM-DD-YYYY
SSN: *
ex. XXX-XX-XXXX
Company or DBA:
Tax ID or EIN:
ex. XX-XXXXXXX
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Confirm Email: *
Password: *
Confirm Password: *
Cell Phone: *
ex. XXX-XXX-XXXX
Alt Phone:
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Address: *
City: *
State: *
Zip: *
Upline 1 Number: *
ex. PW00001
Upline 1 Percent: *
Office 1: *
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Upline 2 Number: *
ex. PW54321
Upline 2 Percent: *
Office 2: *
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ACH Deposit Information
Account Name: *
Account Type: *
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Account Number: *
Routing Number: *
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