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<form id="inf_form_3f71c00a94d36f3139b9a849b793215b" class="infusion-form" accept-charset="UTF-8" action="https://beliefcloset.infusionsoft.com/app/form/process/3f71c00a94d36f3139b9a849b793215b" method="POST">
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<div class="imageSnippet-alignDiv"><img class="simage" title="Interesting Image" src="https://d1yoaun8syyxxt.cloudfront.net/beliefcloset-d0c3a1d5-c389-4ad8-a263-5ef7f9a5dff9-v2" alt="Interesting Image" width="585" height="142" align="bottom" border="0" /></div>
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<strong>
Referral Partner Registration
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<div class="infusion-field"><label for="inf_field_FirstName">First Name *</label>
<input id="inf_field_FirstName" class="infusion-field-input-container" name="inf_field_FirstName" type="text" placeholder="First Name *" /></div>
<div class="infusion-field"><label for="inf_field_LastName">Last Name *</label>
<input id="inf_field_LastName" class="infusion-field-input-container" name="inf_field_LastName" type="text" placeholder="Last Name *" /></div>
<div class="infusion-field"><label for="inf_field_Email">Email *</label>
<input id="inf_field_Email" class="infusion-field-input-container" name="inf_field_Email" type="text" placeholder="Email *" /></div>
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<div class="infusion-field"><label for="inf_field_Company">Company</label>
<input id="inf_field_Company" class="infusion-field-input-container" name="inf_field_Company" type="text" placeholder="Company" /></div>
<div class="infusion-field"><label for="inf_field_Phone1">Phone Number *</label>
<input id="inf_field_Phone1" class="infusion-field-input-container" name="inf_field_Phone1" type="text" placeholder="Phone Number *" /></div>
<div class="infusion-field"><label for="inf_field_StreetAddress1">Street Address 1 *</label>
<input id="inf_field_StreetAddress1" class="infusion-field-input-container" name="inf_field_StreetAddress1" type="text" placeholder="Street Address 1 *" /></div>
<div class="infusion-field"><label for="inf_field_StreetAddress2"> Street Address 2</label>
<input id="inf_field_StreetAddress2" class="infusion-field-input-container" name="inf_field_StreetAddress2" type="text" placeholder=" Street Address 2" /></div>
<div class="infusion-field"><label for="inf_field_City"> City *</label>
<input id="inf_field_City" class="infusion-field-input-container" name="inf_field_City" type="text" placeholder=" City *" /></div>
<div class="infusion-field"><label for="inf_field_State">State *</label>
<input id="inf_field_State" class="infusion-field-input-container" name="inf_field_State" type="text" placeholder="State *" /></div>
<div class="infusion-field"><label for="inf_field_PostalCode"> Postal Code *</label>
<input id="inf_field_PostalCode" class="infusion-field-input-container" name="inf_field_PostalCode" type="text" placeholder=" Postal Code *" /></div>
<div class="infusion-field"><label for="inf_field_Country">Country *</label>
<div class="infusion-field-input-container"><select id="inf_field_Country" name="inf_field_Country">
<option value="">Please select one</option>
<option value="Afghanistan">Afghanistan</option>
<option value="Åland Islands">Åland Islands</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas (the)">Bahamas (the)</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia (Plurinational State of)">Bolivia (Plurinational State of)</option>
<option value="Bonaire, Sint Eustatius and Saba">Bonaire, Sint Eustatius and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory (the)">British Indian Ocean Territory (the)</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cabo Verde">Cabo Verde</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cayman Islands (the)">Cayman Islands (the)</option>
<option value="Central African Republic (the)">Central African Republic (the)</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos (Keeling) Islands (the)">Cocos (Keeling) Islands (the)</option>
<option value="Colombia">Colombia</option>
<option value="Comoros (the)">Comoros (the)</option>
<option value="Congo (the Democratic Republic of the)">Congo (the Democratic Republic of the)</option>
<option value="Congo (the)">Congo (the)</option>
<option value="Cook Islands (the)">Cook Islands (the)</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Côte d'Ivoire">Côte d'Ivoire</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czech Republic (the)">Czech Republic (the)</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic (the)">Dominican Republic (the)</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands (the) [Malvinas]">Falkland Islands (the) [Malvinas]</option>
<option value="Faroe Islands (the)">Faroe Islands (the)</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories (the)">French Southern Territories (the)</option>
<option value="Gabon">Gabon</option>
<option value="Gambia (the)">Gambia (the)</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See (the)">Holy See (the)</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran (Islamic Republic of)">Iran (Islamic Republic of)</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Johnston Island">Johnston Island</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea (the Democratic People's Republic of)">Korea (the Democratic People's Republic of)</option>
<option value="Korea (the Republic of)">Korea (the Republic of)</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic (the)">Lao People's Democratic Republic (the)</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Macedonia (the former Yugoslav Republic of)">Macedonia (the former Yugoslav Republic of)</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands (the)">Marshall Islands (the)</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia (Federated States of)">Micronesia (Federated States of)</option>
<option value="Midway Islands">Midway Islands</option>
<option value="Moldova (the Republic of)">Moldova (the Republic of)</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands (the)">Netherlands (the)</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger (the)">Niger (the)</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="Northern Mariana Islands (the)">Northern Mariana Islands (the)</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine, State of">Palestine, State of</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines (the)">Philippines (the)</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Réunion">Réunion</option>
<option value="Romania">Romania</option>
<option value="Russian Federation (the)">Russian Federation (the)</option>
<option value="Rwanda">Rwanda</option>
<option value="Saint Barthélemy">Saint Barthélemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin (French part)">Saint Martin (French part)</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten (Dutch part)">Sint Maarten (Dutch part)</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option>
<option value="South Sudan">South Sudan</option>
<option value="Southern Rhodesia">Southern Rhodesia</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan (the)">Sudan (the)</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Swaziland">Swaziland</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syrian Arab Republic">Syrian Arab Republic</option>
<option value="Taiwan (Province of China)">Taiwan (Province of China)</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania, United Republic of">Tanzania, United Republic of</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkey">Turkey</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands (the)">Turks and Caicos Islands (the)</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates (the)">United Arab Emirates (the)</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States">United States</option>
<option value="United States Minor Outlying Islands (the)">United States Minor Outlying Islands (the)</option>
<option value="Upper Volta">Upper Volta</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela (Bolivarian Republic of)">Venezuela (Bolivarian Republic of)</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands (British)">Virgin Islands (British)</option>
<option value="Virgin Islands (U.S.)">Virgin Islands (U.S.)</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
</select></div>
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<div class="text">
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Choose a Username of approximately 4 to 8 letters.

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<div class="infusion-field"><label for="inf_other_Username">Username *</label>
<input id="inf_other_Username" class="infusion-field-input-container" name="inf_other_Username" type="text" placeholder="Username *" /></div>
<div class="infusion-field"><label for="inf_other_Password">Password *</label>
<input id="inf_other_Password" class="infusion-field-input-container" name="inf_other_Password" type="password" placeholder="Password *" /></div>
<div class="infusion-field"><label for="inf_other_RetypePassword">Confirm Password *</label>
<input id="inf_other_RetypePassword" class="infusion-field-input-container" name="inf_other_RetypePassword" type="password" placeholder="Confirm Password *" /></div>
<div></div>
<div class="infusion-field"><label for="inf_other_NotifyOnSale">Notify on Sale</label>
<div class="infusion-radio">
<div class="options-container"><span class="infusion-option">
<input id="inf_other_NotifyOnSale_1" name="inf_other_NotifyOnSale" type="radio" value="1" />
<label for="inf_other_NotifyOnSale_1">Yes</label>
</span><span class="infusion-option">
<input id="inf_other_NotifyOnSale_0" name="inf_other_NotifyOnSale" type="radio" value="0" />
<label for="inf_other_NotifyOnSale_0">No</label>
</span></div>
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<div class="infusion-field"><label for="inf_field_SSN">SSN (U.S. Residents Only)</label>
<input id="inf_field_SSN" class="infusion-field-input-container" name="inf_field_SSN" type="text" placeholder="SSN (U.S. Residents Only)" /></div>
<div class="infusion-field"><label for="inf_custom_EIN">EIN (U.S. Businesses Only)</label>
<input id="inf_custom_EIN" class="infusion-field-input-container" name="inf_custom_EIN" type="text" placeholder="EIN (U.S. Businesses Only)" /></div>
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<div class="infusion-field"><span class="infusion-option">
<input id="inf_option_ClickhereifyouareaCertifiedClearYourBeliefsCoach" name="inf_option_ClickhereifyouareaCertifiedClearYourBeliefsCoach" type="checkbox" value="1402" />
<label for="inf_option_ClickhereifyouareaCertifiedClearYourBeliefsCoach">Click here if you are a Certified Clear Your Beliefs Coach</label>
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<div class="infusion-field"><span class="infusion-option">
<input id="inf_option_PleaseMailMyCommissionPaymenttothePaypalEmailAddressBelow" checked="checked" name="inf_option_PleaseMailMyCommissionPaymenttothePaypalEmailAddressBelow" type="checkbox" value="976" />
<label for="inf_option_PleaseMailMyCommissionPaymenttothePaypalEmailAddressBelow">Please Mail My Commission Payment to the Paypal Email Address Below:</label>
</span></div>
<div class="infusion-field"><label for="inf_custom_PaypalEmailAddress">Paypal Email Address *</label>
<input id="inf_custom_PaypalEmailAddress" class="infusion-field-input-container" name="inf_custom_PaypalEmailAddress" type="text" placeholder="Paypal Email Address *" /></div>
<div>
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<div class="infusion-submit"><button id="recaptcha_3f71c00a94d36f3139b9a849b793215b" class="infusion-recaptcha" type="submit">Register!</button></div>
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