1. INDEPENDENT REPRESENTATIVE INDEPENDENT REPRESENTATIVE
Name_________________________________ Name_________________________________
Address_______________________________ Address_______________________________
City_____________ State _____Zip_________ City_____________ State _____Zip_________
Phone ________________________________ Phone ________________________________
Email_________________________________ Email_________________________________
RFL Team or Individual___________________ RFL Team or Individual___________________
**Make Checks Payable to American Cancer Society **Make Checks Payable to American Cancer Society
INDEPENDENT REPRESENTATIVE INDEPENDENT REPRESENTATIVE
Name_________________________________ Name_________________________________
Address_______________________________ Address_______________________________
City_____________ State _____Zip_________ City_____________ State _____Zip_________
Phone ________________________________ Phone ________________________________
Email_________________________________ Email_________________________________
RFL Team or Individual___________________ RFL Team or Individual___________________
**Make Checks Payable to American Cancer Society **Make Checks Payable to American Cancer Society
INDEPENDENT REPRESENTATIVE INDEPENDENT REPRESENTATIVE
Name_________________________________ Name_________________________________
Address_______________________________ Address_______________________________
City_____________ State _____Zip_________ City_____________ State _____Zip_________
Phone ________________________________ Phone ________________________________
Email_________________________________ Email_________________________________
RFL Team or Individual___________________ RFL Team or Individual___________________
**Make Checks Payable to American Cancer Society **Make Checks Payable to American Cancer Society
INDEPENDENT REPRESENTATIVE INDEPENDENT REPRESENTATIVE
Name_________________________________ Name_________________________________
Address_______________________________ Address_______________________________
City_____________ State _____Zip_________ City_____________ State _____Zip_________
Phone ________________________________ Phone ________________________________
Email_________________________________ Email_________________________________
RFL Team or Individual___________________ RFL Team or Individual___________________
**Make Checks Payable to American Cancer Society **Make Checks Payable to American Cancer Society
INDEPENDENT REPRESENTATIVE INDEPENDENT REPRESENTATIVE
Name_________________________________ Name_________________________________
Address_______________________________ Address_______________________________
City_____________ State _____Zip_________ City_____________ State _____Zip_________
Phone ________________________________ Phone ________________________________
Email_________________________________ Email_________________________________
RFL Team or Individual___________________ RFL Team or Individual___________________
**Make Checks Payable to American Cancer Society **Make Checks Payable to American Cancer Society