<h1 style="text-align: center;"><span style="color: #000080;"><strong>Click here if you are a Certified Clear Your Beliefs Coach</strong></span></h1>
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                                    <span>Referral Partner Registration </span>
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    <div class="infusion-field">
        <label for="inf_field_FirstName">First Name *</label>
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        <label for="inf_field_StreetAddress2"> Street Address 2</label>
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        <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>
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        <div>&nbsp;</div>
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Choose a Username of approximately 4 to 8 letters. Enter either your SSN or EIN # below.
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    <div class="infusion-field">
        <label for="inf_other_Username">Username *</label>
        <input class="infusion-field-input-container" id="inf_other_Username" name="inf_other_Username" placeholder="Username *" type="text" />
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        <label for="inf_other_Password">Password *</label>
        <input class="infusion-field-input-container" id="inf_other_Password" name="inf_other_Password" placeholder="Password *" type="password" />
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        <label for="inf_other_RetypePassword">Confirm Password *</label>
        <input class="infusion-field-input-container" id="inf_other_RetypePassword" name="inf_other_RetypePassword" placeholder="Confirm Password *" type="password" />
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                    <input id="inf_other_NotifyOnLead_1" name="inf_other_NotifyOnLead" type="radio" value="1" />
                    <label for="inf_other_NotifyOnLead_1">Yes</label>
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                <span class="infusion-option">
                    <input id="inf_other_NotifyOnLead_0" name="inf_other_NotifyOnLead" type="radio" value="0" />
                    <label for="inf_other_NotifyOnLead_0">No</label>
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    <div class="infusion-field">
        <label for="inf_other_NotifyOnSale">Notify on Sale</label>
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            <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>
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                    <input id="inf_other_NotifyOnSale_0" name="inf_other_NotifyOnSale" type="radio" value="0" />
                    <label for="inf_other_NotifyOnSale_0">No</label>
                </span>
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    </div>
    <div class="infusion-field">
        <label for="inf_field_SSN">SSN  (U.S. Residents Only)</label>
        <input class="infusion-field-input-container" id="inf_field_SSN" name="inf_field_SSN" placeholder="SSN  (U.S. Residents Only)" type="text" />
    </div>
    <div class="infusion-field">
        <label for="inf_custom_EIN">EIN (U.S. Businesses Only)</label>
        <input class="infusion-field-input-container" id="inf_custom_EIN" name="inf_custom_EIN" placeholder="EIN (U.S. Businesses Only)" type="text" />
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        <div>&nbsp;</div>
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            <label for="inf_option_ClickhereifyouareaCertifiedClearYourBeliefsCoach">Click here if you are a Certified Clear Your Beliefs Coach</label>
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        <div>&nbsp;</div>
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            <label for="inf_option_PleaseMailMyCommissionPaymenttothePaypalEmailAddressBelow">Please Mail My Commission Payment to the Paypal Email Address Below:</label>
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