PMRNC Order Form

Checks/Money Orders payable to:

K&L Media, LLC
Linda Walker
P.O. Box 507
Au Sable Forks, NY 12912

Fax To:  (484) 214-0101
Or
Email to (scan)   linda@billerswebsite.com

Name: ___________________________________________

Company Name: ___________________________________

Mailing Address: ___________________________________

Home Phone: ____________________

Business Phone: __________________

Fax: ___________________________

Email: _____________________   (please be sure to print clearly as you will receive a verification via email from us)

Store Front Order Code:______________ 

Order Details: _______________________________________________________

If this is a subscription, do you want to be listed within our billing center listing area?

Yes    No

If yes  how would you like your listing to appear?  (maximum of 7 lines; see example below)

Billing Company Name (website address, if applicable):  ____________________________________________
Owner's Name
Business or home address
City, State, Zip
Phone
Fax
email

Comments or other order directions/options:

If you are purchasing a subscription, please be sure you have read and agree to the terms of the subscriber agreement located at: http://www.billerswebsite.com/subscriberagreement.htm

Yes I have read and agree to the terms of the Subscriber Agreement.  _________ (initial)

Signature: ____________________________

If you wish to pay by credit card via fax, please complete the bottom portion of this form and fax it back to (484) 214-0101

Name as it appears on your Credit Card __________________________

Credit Card Billing Address: ________________________   City: ________________ State____  Zip Code:________

Credit Card Number __________________________________________

Expiration Date: ____________________  CVS2 (last 3 digits on back of your credit card) _____________

I authorize PMRNC to debit my credit card in the amount of $________.  I understand that I will receive a confirmation email as my receipt and that no further charges will be billed to my credit card without my knowledge.

Cardholder Signature: _________________________________________