Member Information

State which TV Show in our TV network you are supporting.

Your Company or Organization:

Referring Affiliate ID:

Your Last Name:       Your First Name:   

If you would like to include your spouse on your membership enter it here:

Spouse Last Name:    Spouse First Name: 

Street Address:  

City:         State:              Zip:

Best Contact Number:      Telephone 2: 

Cell Phone:     E-mail:

Student     Retired       Senior Citizen    Unemployed    Self Employed

Employed  If yes, state occupation:        

I am 18 and over

I need to set up my website upon signing up as a QLTV member

I need more information about QLTV web hosting services.

List your areas of interest:

See ATVN Member Details Here See Affiliate Producer Details Here

Select Member Type: ATVN Member $60/year:1, 2, or 3 payments Producers Network $25/month Affiliate Producer Package (1) – $45/month: requires 1,2 or 4 Payments - $250 one-time setup fee Affiliate Producer Package (2) – $75/month: requires 1,2 or 4 Payments - $250 one-time setup fee Affiliate Producer Package (3) – $95/month: requires 1,2 or 4 Payments - $250 one-time setup fee

Choose Payment Option Monthly Quarterly Semi-Annually Annually                                               Choose Payment Method Credit/Debit Card

(Please contact us to make payment by Check or Money Order. 

Please note that payment made by check or money order must be paid in full for the year.)

Card Type        Master Card Visa

Card Number 

Expiration Date:          Security Code:

Name on Card: 

Street Address:

City          State:         Zip: 

MEMBERSHIP:

1)  I hereby apply for membership as an member in the Amali Television Network and, if accepted, agree to abide by

     all the rules and policies set forth by the organization. Further, I certify that the foregoing information is correct.

2)  I understand that I have the right to cancel my membership within 3 days after submitting this form and upon reviewing

     my application with a full refund of payments all made.

3)  I understand that the organization has the right to cancel my membership after reviewing my application with a full refund

     of all payments made.

4)  I also understand that the full setup/application fee must be paid and membership fee in part or in full for the first year

     must be paid before my membership can be activated.

5)  I also understand that the organization has the right to cancel my membership at any time for any reason, and that if after

     the initial 3 days I choose to cancel this membership, the signup fee is non-refundable.

6)  I also understand that my membership is automatically renewed after 1 year unless I request cancellation of my

     membership in writing. 

(7) I also understand that the organization has the right to cancel my membership at any time for any reason, and that if after

     the initial 3 days I choose to cancel this membership, the membership fee will be refunded on a pro-rata basis, the one-time

     setup application fee is non-refundable.

I agree to become an ATVN Member and to abide by the policies.