MA Lite Signup Form

9-Digit Distributor ID

Email Address

Phone Number

Payment Information

Payment Amount: $100.00

Name on card

Card number

Expiration date
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I authorize iTransact to charge my card a non-refundable first-year service fee of $100.00. I agree to be charged a $59.00 annual service fee on or near this date next year and each year thereafter until I cancel my iTransact MA Lite service.