MEMBERSHIP
FAX FORM - U.S.
Fill
out all the information then print this form.
Include your credit card information below and
fax this form to: 1-
818 - 954 - 9283
One
Bottle of Liquid Rx, One Bottle of Liquid Rx Plus
&
The Free Penis Enlargement Program!
- Length
of Membership:
-
One
Month - $39.85
-
Two
Months - $79.70
-
Three
Months - $119.55
Bill to:
Name
Street
Address
Address line 2
City
State
Zip/Postal Code
Country
Email address
(You must include your email address)
Phone Number (including area code)
- Credit
Card Information:
-
- Please
check the credit card you are using:
Visa
MasterCard
American Express
Discover
Name on Card
Card
Number
Expiration
Date (MM/YY)
Signature
______________________________________
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