Please Print Carefully or Type All fields are REQUIRED. Incomplete forms will not be processed. Please use only one form per purchase. ---------------- YOUR INFORMATION ---------------- Name: _______________________________________________________________________ Email Address: ______________________________________________________________ IMPORTANT! This is the only way we will contact you when your account has been set up and is running properly. Billing Address: ____________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ I certify I am over 18 years of age. Signature: __________________________________________________________________ -------- PRODUCTS -------- Choose the Model from the list below and calculate the appropriate charges. Please use only one form per purchase. If you would like to make multiple purchases, please print multiple forms. __ Bosombox.com $29.95 x ____ months = $____________ TOTAL __ Bosombox2.com $29.95 x ____ months = $____________ TOTAL __ Bosombox3.com $29.95 x ____ months = $____________ TOTAL __ Chelsea Charms $29.95 1st month + $19.95 x ____ months = $_______TOTAL __ Pandora Peaks $29.95 1st month + $19.95 x ____ months = $_______TOTAL __ Patty Please $19.95 1st month + $9.95 x ____ months = $_______TOTAL __ Maxi Mounds $19.95 x ____ months = $_______TOTAL __ Crystal Storm $19.95 x ____ months = $_______TOTAL __ Asley Evans $19.95 x ____ months = $_______TOTAL __ Colt 45 $19.95 x ____ months = $_______TOTAL __ Lisa Lipps $19.95 x ____ months = $_______TOTAL __ SaRenna Lee $19.95 x ____ months = $_______TOTAL __ Plenty UpTopp $19.95 x ____ months = $_______TOTAL __ BB Gunns $19.95 x ____ months = $_______TOTAL __ Crystal Gunns $19.95 x ____ months = $_______TOTAL __ Teddi Barrett $19.95 x ____ months = $_______TOTAL __ Casey James $19.95 x ____ months = $_______TOTAL __ Dixie Bubbles $19.95 x ____ months = $_______TOTAL __ Savanna Staxx $19.95 x ____ months = $_______TOTAL __ Lulu Devine $19.95 x ____ months = $_______TOTAL __ Donita Dunes $19.95 x ____ months = $_______TOTAL __ Shayne Fawntanna $19.95 x ____ months = $_______TOTAL __ Echo Valley $19.95 x ____ months = $_______TOTAL __ Fantasia $19.95 x ____ months = $_______TOTAL __ Keisha Evans $19.95 x ____ months = $_______TOTAL __ Kandi Cox $19.95 x ____ months = $_______TOTAL __ Colette Dupree $19.95 x ____ months = $_______TOTAL __ Nikki Diamond $19.95 x ____ months = $_______TOTAL __ Letha Weapons $19.95 x ____ months = $_______TOTAL __ Kimberly Kupps $19.95 x ____ months = $_______TOTAL __ Sierra $19.95 x ____ months = $_______TOTAL __ Lola Lane $19.95 x ____ months = $_______TOTAL __ XXXena $19.95 x ____ months = $_______TOTAL __ Melody Foxxe $19.95 x ____ months = $_______TOTAL __ Heather Hooters $19.95 x ____ months = $_______TOTAL __ Randi Rushmore $19.95 x ____ months = $_______TOTAL __ Harmony Bliss $19.95 x ____ months = $_______TOTAL __ Ricki Raxxx $19.95 x ____ months = $_______TOTAL __ Kitten Natividad $9.95 x ____ months = $_______TOTAL __ Windy Leigh $9.95 x ____ months = $_______TOTAL __ Summer Cummings $9.95 x ____ months = $_______TOTAL __ April Chest $9.95 x ____ months = $_______TOTAL __ Tippi Topps $9.95 x ____ months = $_______TOTAL __ Misty & Tara $9.95 x ____ months = $_______TOTAL __ Bunny Glamazon $9.95 x ____ months = $_______TOTAL __ Sugar Kane $9.95 x ____ months = $_______TOTAL __ Honey Melons $9.95 x ____ months = $_______TOTAL Desired Username: __________________________________________________________ (at least 8 characters and it is case sensitive) Alternate: _________________________________________________________________ (in case first selection is taken) Desired Password: __________________________________________________________ ------- PAYMENT ------- Please Make Check or Money Order IN U.S. DOLLARS ONLY Payable to: KCW, Inc PO Box 17403 Raleigh, NC 27619 Please be sure to include a copy of your Drivers License or another form of picture ID (military ID, State issued ID, etc). You will be emailed when your account is set up and operating. Thank you, PhotoClubs.Com webmaster@photoclubs.com