BONDAGE THRILLERS
Mail And Fax Order Form
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MAILING INFORMATION:
Include your check or money order paying
for the term you wish to join, and mail to:
MaL Content Media 304 Main Avenue - Suite 250, Norwalk, CT 06851
Make all checks payable to: MaL Content Media, LLC
Money Order memberships will
be active within 24 hours of receipt of payment
ALL Personal Checks must clear
the bank before your
membership will be activated, this may take up to 14 days.
FAXING INFORMATION:
Fax this completed form to the following number 203 - 849 - 1594
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YOUR FULL
NAME:____________________________________________________________
STREET ADDRESS:___________________________________________________________
CITY:______________________ STATE:_____________________ ZIP CODE:_____________
COUNTRY:___________________________________________________________________
PHONE NUMBER:_____________________________________________________________
E-MAIL ADDRESS (required):________________________________________________
TOTAL AMOUNT YOU OWE (In US Currency) $_________________________________
MEMBERSHIP - NON-RECURRING
One month = $9.95 Three months = $25.95 Six months = $47.95
CHOOSE A USER NAME:________________________________
(up to 8 letters/numbers)
CHOOSE A PASSWORD:________________________________
(up to 8 letters/numbers)
YOUR CREDIT CARD NUMBER (FOR FAX ONLY):__________________________________
YOUR CREDIT CARD'S EXPIRATION
DATE:__________________
YOUR SIGNATURE: __________________________________________________________
Certifying you are an adult and over 18 years old.
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