Please Complete the following,
and print clearly:
Your Name:
_______________________________________________________
Mailing Address:
________________________________________________
City:
_________________________________________________________
State/Province: ________________________________
Country:
______________________ Zip/Postal Code: ________________
Email address**: _________________________________
Phone # Including Area Code: ____________________________
**IF you are using an AOL address, you
MUST Supply us with either your phone number, OR an alternate email
address outside of AOL**. This is because AOL is known to
block emails.
** Alternate Email if Required as above:
__________________________________
Within a short time of receiving your order
submission, you will receive an email. This email contains a URL where I need
you to go and submit your information. This gives you a chance to gather your
thoughts and decide on what you want to promote.