VIP Customer Registration Form

*Required fields must be completed!

First Name* Last Name* Area Code*          Number*   Address 1* Address 2 City* State*  Zip Code*   E-mail*     Please choose one of the following options:   I am Registering for :       FREE Send me 1 Trial VIP Card - (1 VIP Card per person)**      Store Purchase Please register my VIP Membership that purchased at : (required) Store Name       $9.95 Yes I would like a VIP Membership (payment information required) One payment option must be completed to order a VIP Membership. Credit Card # CVA Number    (3 digit number located on the signature strip) Expiration Date   ( mm/yy ) Virtual Check - Fee will be charged directly to your checking account. Bank Name Account Number Routing Number  (located next to account number)     I understand that by clicking the submit button I am authorizing the SBDA to debit my bank/credit card account for the amount of $9.95 for the purchase of each Annual Vip Card(s)**       Optional This information will only be used to customize special offers. Sex   Male   Female Age Notify me monthly of special offers. How did you hear about us?      Search Engine      Advertisement      Store Display      VIP Card             **One free Trial VIP Card per person per month.       This form may also be submitted by fax to 770-953-8664 or mail.to : SBDA 2470 Windy Hill Road Suite 244 Marietta, GA 30067