VIP Customer Registration Form

*Required fields must be completed!<%=thistext%>

First Name* <%=indnamef%> Last Name* <%=indnamel%> Area Code* <%=indac%>          Number* <%=indphone%>   Address 1* <%=indaddr1%> Address 2 City* <%=indcity%> State* <%=indst%>  Zip Code* <%=indzip%>   E-mail*<%=indemail%>     Please choose one of the following options:   I am Registering for :     <%call raydeeohStat("Free")%>  FREE <%=indstatus%> Send me 1 Trial VIP Card - (1 VIP Card per person)**   <%call raydeeohStat("retail_vip")%>   Store Purchase <%=indstatus%> Please register my VIP Membership that purchased at : (required) Store Name<%=indstore%>     <%call raydeeohStat("online_vip")%>  $9.95 <%=indstatus%> Yes I would like a VIP Membership (payment information required) One payment option must be completed to order a VIP Membership. Credit Card # <%=indpay%> CVA Number <%=indpay%>    (3 digit number located on the signature strip) Expiration Date <%=indpay%>   ( mm/yy ) Virtual Check - Fee will be charged directly to your checking account. Bank Name <%=indpay%> Account Number <%=indpay%> Routing Number <%=indpay%>  (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   <%call raydeeohSex("male")%> Male   <%call raydeeohSex("female")%> Female Age Notify me monthly of special offers. How did you hear about us?      <%call raydeeohAd("search_engine")%> Search Engine      <%call raydeeohAd("advertisement")%> Advertisement      <%call raydeeohAd("store_display")%> Store Display      <%call raydeeohAd("vip_card")%> 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