Payment Method

September 21, 2010
By

Payment Classification*

Subscriber

[   ]  Magazine [   ]  Coupon [   ] Website

Coupons

[   ]  MCAP Vendor Organization [   ]  MCAP Vendor [   ]  MCAP Fundraiser

Advertiser

[   ] Magazine [   ]  Radio [   ]  Coupon [   ] Website

Merchandise

Other

Payment Method

[   ] Individual Tax ID: [   ] Business Tax ID:

Credit Card/Paypal Account #:

Account Holder’s Name Title

Business/Organization Name

Expiration CCV Code

Street Address

City* State* Zip * Country*

Phone* Fax Mobile

E-mail Address

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