Akola Ambassador Application:
First Name:
*
Last Name:
*
Email:
*
Phone:
*
How did you hear about the Akola Project?
*
Please Select
Website
Friend
Church
Advertisement
Word of Mouth
Internet Search
Other
Event Details:
Start Date:
*
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Month
-
Day
Year
Date Picker Icon
1
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11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Total Event Duration (hours):
*
Please Select
1
2
3
4
5
6
7
8
9
10+
Estimated # of Invites:
*
Please Select
1-20
20-50
50-100
100-200
200+
Estimated # of Guests:
*
Please Select
1-20
20-50
50-100
100-200
200+
Preferred Price Range for Items:
*
Please Select
$10
$20
$30
$40
$50
$60
$70
$80
No Preference; Send me a variety
Event Type
*
Please Select
Trunk Show
Cocktail Party
Garden Club
Church Event
Work Event
Other
Event Details:
Credit Card Information
Note: Your card will be used to guarantee the value of the items you receive. Your card will not be charged unless items are not returned two weeks after scheduled end date.
Name on Card:
*
Credit Card Type:
*
Please Select
Visa
Mastercard
Discover
Credit Card #:
*
Security Code:
*
Billing Address:
*
Line 2:
City:
*
State:
*
Zip Code:
*
Necklace Shipping Information
Note: Shipping takes up to two weeks once your credit card has been authorized. Necklaces will be sent to you free of charge and a pre-paid return label will be provided as well.
First Name:
*
Last Name:
*
Shipping Address (No P.O. Boxes)
*
Line 2:
City:
*
State:
*
Zip Code:
*
Special Delivery Instructions:
Agreement:
I hereby understand that I am personally responsible for the full value of all items not returned to UAPO and hereby grant UAPO permission to charge the value of any items not returned to my credit card.
*
I Agree
I Do Not Agree
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