FLORISTA AFFILIATE SIGN UP

After submitting this application, please kindly TEXT the words "SIGN UP" to 561-622-1843.

FIRST NAME:

LAST NAME:

Cell/Text Number

Zip Code

Flower Shop Name

City

State

PRICE LIST: Start today. Link tomorrow.

Be listed on "LOCATIONS by zip code", www.dialarose.com.

	Zip Code Territory one time Purchase. $198.40 (Subject to change)
	Monthly website Link Fee, Video Instructions and SUPPORT $19.84

Visit FLORISTASCHOOL.com to learn more.

OPTIONAL: Credit Card Information: Mastercharge, Visa, American Express, Discover.

Your credit card will not be run until after your application is accepted. Zip codes are first come, first serve. There is only one affiliate per zip code. By sending in this application with credit card information, your zip code will be reserved until the application process is complete. Cancel at any time, either party, for any reason.

Name on Card

Zip Code

Credit Card Type

Credit Card Number

Expiration Date (mm/yy)

Security Code. THANK YOU FOR TRUSTING OUR FINE SERVICE.