Fill
in all the information requested, print a copy, sign
and date and mail it to the address provided.
Last.Name
First
Address
Payment
Cash
Check
CreditCard
City
Credit
Visa
MasterCard
Other
State
Card.#
Zip
Expires
Phone
()
ATM.Card.#
Work
()
Bank.Name
Fax
()
Expires
By signing this document, I
agree that the information provided is 100% accurate
and I agree with the full payment of $20 monthly.
Any false information is subject to criminal
prosecution by Federal Government.
