Application

ENROLLING SPONSOR:
%%firstname%% %%lastname%%,
vccus.com ID# %%idnumber%%
Phone # %%phone%%

PRODUCT NAME	QUANTITY	MONTHLY FEE	TOTAL FEE
My Monthly Web Site Hosting		US $ 50.00 (Required)	$
Add My URL(One Month)		Free with membership	$
Add My URL(Three Months)		Free with membership	$
SCAN MY PICTURE (One)		US $ 10.00	$
SCAN MY PICTURES (Three)		US $ 25.00	$
Design a Web Page		US $ 49.00	$
Design a Web Site (3 pages)		US $ 99.00	$

	BILLING All prices are in US dollars
Credit card
Cardholder name
Card number
Expiration date
PAY BY CHECK NOTE: US CHECKS ONLY
*Check Number:*
*Fraction Number:*	example upper right hand corner of check
*Name of Bank*
*Bank Street Address*
*Bank City, State, Zip*	,
*Bank Phone Number*	*(If known)*
	*Bank Routing NumberAcct Num*
- Please verify all information before submitting
AutoPay This authority will remain in force until canceled by me or vccus.com. If payment is DECLINED by my bank, it will CANCEL this order and any future orders will be on a CASH/MONEY ORDER basis. Type First and Last Name agreeing to AutoPay: Please Select one:

Information deemed reliable but not guaranteed. Prices, features, and availability are subject to change without notice. Void where prohibited by law. Not an offering where prior registration is required. Equal Housing Opportunity.

First, Middle Initial and Last Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Home Phone
FAX
E-mail
Professioanl License #
TAX ID# ( SS# FED ID# for compensation only)
Your Web Site Title
Your Web Site URL
Keywords
Description and Comments