Pivotal Wealth Agent Registration

First Name: *

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

Job/Position: *

School Name:

District:

Email: *

Confirm Email: *

Password: *

Confirm Password: *

Cell Phone: *

ex. XXX-XXX-XXXX

Alt Phone:

ex. XXX-XXX-XXXX

Address: *

City: *

State: *

Zip: *

Upline 1 Number: *

ex. PW00001

Upline 1 Percent: *

I confirm that

Upline 2 Number: *

ex. PW54321

Upline 2 Percent: *

I confirm that

I agree

Please check 'I agree' at the bottom of each disclosure after reviewing.

ACH Deposit Information

Account Name: *

Account Type: *

Account Number: *

Routing Number: *

W-9 Information

Payment Details

Agent registration fee:

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We do not store your credit card information.

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Welcome to Pivotal Wealth

Congratulations!

Welcome to the team! Your registration is now being processed. Your agent registration fee in the amount of $179 was charged successfully.

Your Agent ID is .