Mail/Fax Subscription Form
First/Last Name: ______________________________________________________ Company Name: _________________________________________________________ Job Position: _________________________________________________________ Billing Address: ______________________________________________________ City, State Zip: ______________________________________________________ Company Phone (xxx-xxx-xxxx): _________________________________________ FAX Phone (xxx-xxx-xxxx): _____________________________________________ Username (25 characters or less): _____________________________________ Password (12 characters or less): _____________________________________ E-mail Address: _______________________________________________________ Promotions Package [ ] $10.00 (billed monthly) (U.S. and Canada only) [ ] $30.00 for 3 months (save $5) [ ] $60.00 for 6 months (save $15) [ ] $100.00 for one year (two months free) [ ] Re-invoice at the end of the subscription period Show Prep/Promotions Package [ ] $35.00 (billed monthly) (U.S. and Canada only) [ ] $100.00 for 3 months (save $5) [ ] $200.00 for 6 months (save $15) [ ] $350.00 for one year (two months free) [ ] Re-invoice at the end of the subscription period Note: Subscription fees are payable in U.S. funds only. [ ] Bill Me (Radio Stations/Companies Only) [ ] Payment Enclosed [ ] Visa [ ] MasterCard [ ] American Express Credit Card Number: ______________________________________ Card Expiration Date: _ _ / _ _ Print your name EXACTLY as it appears on the card: _______________________________________________________________________ Signature: _____________________________________ Date:________________ Credit card orders may be faxed to 806-352-3677. For monthly billing inquiries, contact Customer Support at support.radioonline.com. Return this form and make checks payable to: RADIO ONLINE, 3500 Tripp Ave, Amarillo, TX, 79121. RADIO ONLINE will issue notification via e-mail when subscription is active.
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