Welcome To Our
Electronic Order Form

Ordering methods:
Pay On line with secure ordering form.
Call or fax in credit card number.
Mail or fax in order form.

Level of subscription:
Platinum
Best VALUE!		 Choose up to 300 addresses per month - only 95.00 first month! (£63.3 UKP) Platinum Renewal only $19.95 (£13.30 UKP) per month! Includes addresses (up to 100 each month) to 30,000+ existing profiles, and 850+ new profiles each month!
Platinum package not available by
postal mail.		 [More information on the Platinum subscription level]
Gold 3 to 13 addresses at $7.00 (£4.5 UKP) per address. [More information on the Gold subscription level]
Silver 1 to 2 addresses at $9.00 (£6.00 UKP) per address. [More information on the Silver subscription level]

First Name: Last Name:
Email Address:
Street Address:
City: State: Zip Code:
Country: Phone Number:

The woman's identification code(s):

1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18 19 20
21 22 23 24 25 26 27 28 29 30
31 32 33 34 35 36 37 38 39 40

Platinum members may order additional address after you account is set up. Members

How would you like to receive the addresses?

(If you have purchased the Platinum membership, an account will automatically be established for you. Just go to the "Members Address Retrieval" page and fill in the information, please be sure to use the same E-mail address that you set up the membership with. The system will automatically keep tract of how much time and addresses you have remaining. You will receive an updated status report of your account each time you request an address or addresses. If you prefer to receive the addresses by one of the methods listed below please indicate by checking the preferred method, Platinum members must receive addresses by E-mail.)
E-mailed list of the addresses (No Charge)
Platinum package not available by postal mail!
U.S. Mail (there is a $3.00 fee for mailing anywhere in the United States)

FedEx or US Express Mail (for PO boxes) ($15 fee)
Fax (there is a $15.00 service fee for faxing anywhere in the United States)
If this method has been chosen please enter your fax number -
Registered International Air Mail ($15.00 fee)
International Express Mail (there is a $25.00 fee outside of the United states)

The information requests below are strictly on a volunteer basis, but we would appreciate your input!!!

If you would not like to continue with the questions below click on the submit button above, to submit all of the vital information you have already entered

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