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Member Name: _______________________________________________
Member contact
information, if different from/In need of up-date from current info on
file:
Street Address:
________________________________________________
City/State/Zip: _____________________________________________
Phone:
______________________ Fax: ________________________
e-Mail:
__________________________________________
Note: Providing the above information constitutes permission for
Emory Marketing Systems LLC. to contact member via these means with
updates, special offers and other information.
Credit Card #:
_________________________________
Exp Date:
_______________ Zip Code __________________
Signature of
Cardholder: ___________________________________________
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Yes Lloyd, Count me in.