SouthernCapturedBelles.com
Mail-in Membership Form
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MAILING INFORMATION:
Include your Check or US $ Money Order paying
for the term you wish to join for, and mail to:
Emily Addison
PO Box 273
Mount Holly, NC 28120
Make all checks payable to:
Emily Addison
US $ Money Order memberships will
be active within 24 hours of receipt of payment.
ALL Personal Checks must clear
the bank before your
membership will be activated, this may take up to 14 days.
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YOUR FULL
NAME:__________________________________________________________
STREET ADDRESS:__________________________________________________________
CITY:______________________ STATE:_________________ ZIP CODE:_____________
COUNTRY:________________________________________________________________
PHONE NUMBER:___________________________________________________________
E-MAIL ADDRESS (required):_________________________________________________
PLEASE CHOOSE THE TYPE OF MEMBERSHIP - ALL
ARE NON-RECURRING:
One Month Membership = $17.95
Two Month Membership = $29.95
Three Month Membership = $37.95
TOTAL AMOUNT YOU OWE (In US Currency) $___________________________________
CHOOSE A USER NAME:_____________________________________________________
(up to 8 letters/numbers - this is case sensitive please print if using
capital letters)
CHOOSE A PASSWORD:_____________________________________________________
(up to 8 letters/numbers - this is case sensitive please print if using
capital letters)
YOUR SIGNATURE: _________________________________________________________
Certifying you are an adult and over 18 years old. |