Discounted 6Beds Affiliate Vendor

Individual/Business Name*
Business Email Address*
Phone Number*
Fax Number
Website
Business Address*
Street Address Address Line 2 City State ZIP Code
Service and/or Product*
Primary Contact Name
First Last
Contact Title*
Contact Email*
Enter Email Confirm Email
Contact Phone*
Choose Membership*
- $3,600 - Tier 1(Annual-D)
- $900 - Tier 1 (Quarterly-D)
- $300 - Tier 1 (Monthly-D)
- $1,200 - Tier 2(Annual-D)
- $300 - Tier 2 (Quarterly-D)
- $100 - Tier 2 (Monthly-D)
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Membership Terms
I agree to the following terms: 1) 6Beds membership dues for one (1) year, payable by credit card and the member’s chosen payment frequency of monthly, quarterly, semi-annually or annually; 2) I understand that I can cancel the membership on or after the anniversary date; 3) Membership cannot be cancelled prior to the anniversary date. I acknowledge that the origination of automatic electronic payment to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card account and will not dispute the scheduled transactions with my credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

6BEDS is a Mutual Benefit NON-PROFIT Corporation. Membership fees may be tax deductible (consult with your tax advisor) and are non-refundable.
Vendor Member Signature*

6Beds, Inc.