BIG RAGS BIG TOP--MEMBERS ONLY

MEMBERSHIP APPLICATION

NAME___________________________________________________

ADDRESS________________________________________________(YOUR SHIPPING ADDRESS)

CITY___________________ STATE/PROVINCE________ COUNTRY_______________ZIP________________

email__________________________________________

CREDIT CARD#(if you prefer to not use the internet) ________________________EXP:__________
MEMBERSHIPS ARE RECURRING BUT IF YOU PAY BY MONEY ORDER OR CHECK YOU WILL OBVIOUSLY HAVE TO PAY AGAIN TO CONTINUE MEMBERSHIP

CHECK ONE

___AMAZON LOVER--- $99.99 (INCLUDES 1 YEAR MEMBERSIP, $5 DISCOUNT ON ALL BIG RAGS MERCHANDISE ORDERS OVER $20.00, AND A BIG RAGS MEMBERS COMPILATION VIDEO)(PLEASE NOTE IF YOU NEED PAL FORMAT)

___BIG RAGS BUDDIES---$59.99 (INCLUDES 6 MONTH MEMBERSHIP, $5 DISCOUNT ON ALL BIG RAGS MERCHANDISE ORDERS OVER $20.00 AND A BIG RAGS MEMBERS COMPILATION VIDEO)(PLEASE NOTE IF YOU NEED PAL FORMAT)

___3 MONTH BASIC MEMBERSHIP---$39.99 (INCLUDES 3 MONTH MEMBERSHIP)

___1 MONTH BASIC MEMBERSHIP---$19.99 (INCLUDES 1 MONTH MEMBERSHIP)

WHAT DO YOU WANT YOUR USERNAME TO BE:______________________________

WHAT DO YOU WANT YOUR PASSWORD TO BE:______________________________

REMEMBER THESE ARE CASE SENSITIVE AND IT IS RECOMMENDED THAT YOU MAKE THEM UNIQUE TO THIS SITE

SEND PAYMENT(MONEY ORDER OR CASHIER CHECK PREFERRED AND QUICKER TO GIVE YOU ACCESS) AND MAKE IT PAYABLE TO:
AMAZONICS MEDIA GROUP, PO BOX 1086, FOLSOM, CA 95763