portal.trusa

Agent ID (Not For Customers)

First Name*

Middle Initial

Last Name*

Contact Number*

Alternate No

Street Address*

City*

State*

Zip Code*

Email Address*

Number Of Televisions $15 After 2nd TV

TV 1
TV 2
TV 3
TV 4
TV 5

Add-Ons

Wireless Camera $79.99/

0
1
2
3
4
5

Wireless Doorbell Camera $99.99/

0
1
2
3

Philip Hue Bulbs $39.99/

0
1
2
3
4
5
6
7
8
9
10

Smart Plugs $24.99/

0
1
2
3
4
5
6
7
8
9
10

Notes

Payment Options

Credit/Debit Card
Bank Transfer
PayPal
Western Union Or Money Gram

Credit/Debit Card*

YES
NO

Name On The Card*

Exp (MM-YYYY)*

CVV*

Total ($00.00)

User Agreement

You must be 18 years of age or older and have the legal authority to enter into this Agreement. You affirm that the information you supplied is correct and complete.