Date: ____/____/____

Full Name: _______________________________________________________

Mailing Address: __________________________________________________

City: _________________ GA Zip:____________

Delivery Address ( if different): ________________________________________

City: ________________________ GA Zip: ___________

Contact phone: _______- __________-___________

Email address: _____________________________________

Area of territory requested by zip code, subdivision, neighborhood or other:

________________________________________________________________________

Estimated date of primary order: ________/_________/________

I hereby attest and understand that if I am accepted as an affiliate of the Moms Home Business Network.com , I will be an independent contractor and will be responsible for all my own expenses, marketing and income taxes created by my affiliation. I will represent myself at all times as an affiliate of MHBN.com and will only use information received from MHBN.com as to product description, purpose and cost. All orders will be processed through www.eh20store.com with my referral number included. I will not embellish nor profit from re-sale of products offered through www.eh20store.com and will comply with all laws and regulations pertaining to the sale of goods in the State of Georgia.

Sworn and Attested to:

By:__________________________________________ (print name)

Signed: ____________________________________ (signature) Date: _____/____/____

Email completed form to: affiliate@eh20store.com