LSA -Registration

Pricing:

One-time Set-up Fee: $125.00

Monthly Account Fee: $375.00

Payment Information:

Set-up, Monthly Account, and Processing Fees are required to be paid by credit card.

$500 (One-time Set-up fee of $125 and 1st Monthly Account Fee) is due upon registration.

$375 (Monthly Account Fee) will be automatically charged to your credit card on each monthly anniversary date.

First Name	*
Middle Initial
Last Name	*
Title
Company Name
Address	*
Address
City, State, Zip	*
Telephone (Main)	*
Telephone (Alt)
Facsimile
Email Address	*
Selected Program
		I have read and agree to Life Settlement Administrators’ LSA Licensing and Servicing Agreement. *

	When you click Submit you will be transferred to a secure site and authorizing payment for your initial charge of $500, today, and recurring monthly fees of $375 starting your 2nd month.

	Credit Card Processing