Name:	*
Phone:	*
Contact's Role	Please Choose Agent Event Planner *
Fax:
E-Mail:	*
I have contacted the following client(s) on behalf of Randy Martin & Syndicate I would like to register them with you. I understand that I should expect commission if the client contacts you directly within the next 6 months, and an signed contract to proform results. I further understand that this commission will be paid upon full payment by the client.
My Usual Commission Rate Is:	*
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