Fax Mail Box Setup Sheet

Please provide the following contact information:

First name
Last name
Middle initial
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail
URL

Please bill the following credit card for my Fax Mail Box Rental ($25/month):

American Express
MasterCard
VISA

Enter your name as it appears on your credit card in the space provided below.

Enter your credit card account number in the space provided below.

Enter the expiration date of your credit card in the space provided (month/year):

Your credit card will be charged monthly. Kentucky sales tax will be added if applicable. Submitting this form authorizes this method of payment. (If mailing in this form, enter your signature in the space provided below. Signing below authorizes this method of payment.) Authorized by: