MEMBER APPLICATION and
INITIAL ORDER FORM
Please print the following information clearly. Unreadable applications will NOT be processed.
Member ID : |______|______|______| - |______|______| - |______|______|______|______|
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City, State, Zip Code______________________________________________________________
Phone (______)__________________________________ Birth Date :______/______/_____
| ORDER | PRICING |
| Cigarettes | Quantity | Total Cartons X $14.95 => | |
| Full Flavors | Shipping (1,2 or 3 cartons) = $5.00 => | ||
| Lights | Shipping (4 or more cartons) = FREE => | ||
| Ultralights | Shipping International (CALL) => | ||
| Menthols | New Member Processing Fee = $9.95 => |
| Total Cartons | Optional Forms Package = $4.00 => |
| TOTAL AMOUNT DUE => | |
| I would like this order AUTOSHIPPED every month (YES) => |
| VISA | MC | AMEX | DISCOVER | AUTOPAY |
|____|____|____|____|-|____|____|____|____|-|____|____|____|____|-|____|____|____|____|
CREDIT CARD NUMBER
_________________________________________________ Expiration Date _____/______
Name as it appears on the credit card
I have received, read and understand Stone Tobacco Buyers Club Consumer Direct Marketing, 3 by 9 Reparation Plan and the By-laws which are incorporated herein and made part of this agreement.
Applicant's Signature X _________________________________ Date: _________________
