ClientSource
FAX/MAIL REGISTRATION
Please print this document
then complete the information below and fax or mail to our office.
By Fax: (800)401-6584.
By Mail: ClientSource
136 West Canal Street
Winooski, VT 05404
Once your order has been processed, a customer service representative will contact you by
email or phone with instructions on how to begin the creation of your web site.
CONTACT INFORMATION
First Name: ______________________________
Last Name: ______________________________
Firm: ______________________________
Slogan: ______________________________
Address:
______________________________
______________________________
City: ______________________________
State: _____
Zip Code: _________
Phone Number: (___)______________
Fax Number: (___)______________
Email Address: ______________________________
Desired Domain Name: ______________________________
(if known)
Media Code (if any): ______________
PAYMENT METHOD
Check: ______ Credit Card: ______
BILLING INFORMATION:
Card Type (Circle one) VISA M/C AMEX
Card Number: _______________________________
Expiration: _____/_____
Cardholder Name: _______________________________
Card Billing Address:
Address - Line 1: _______________________________
Address - Line 2: _______________________________
City: _______________________________
State: _____ Zip Code__________
Signature X__________________________________________
*By faxing/mailing your
registration, you are indicating that you have read and agree with, the statement of terms
located on our website.
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