Surrendered Soul / Maidens In
Mayhem
Mail-in Membership Form
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MAILING INFORMATION:
Include your Check or US $ Money Order paying
for the term you wish to join for, and mail to:
The DV8 Design Group
C/O Sea
Side Media, LLC
529 Belleview
Boulevard
Belleair, Florida 33756
Make all checks payable to:
The DV8 Design Group
US $ Money Order memberships will
be active within 24 hours of receipt of payment.
ALL Personal Checks must clear
the bank before your
membership will be activated, this may take up to 14 days.
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YOUR FULL
NAME:__________________________________________________________
STREET ADDRESS:__________________________________________________________
CITY:______________________ STATE:_________________ ZIP CODE:_____________
COUNTRY:________________________________________________________________
PHONE NUMBER:___________________________________________________________
E-MAIL ADDRESS (required):_________________________________________________
TOTAL AMOUNT YOU OWE (In US Currency) $___________________________________
One month = $24.95 - Three months = $45.00
Six months = $75.00 - Twelve months = $150.00
CHOOSE A USER NAME:_____________________________________________________
(up to 8 letters/numbers - this is case sensitive please print if using
capital letters)
CHOOSE A PASSWORD:_____________________________________________________
(up to 8 letters/numbers - this is case sensitive please print if using
capital letters)
YOUR SIGNATURE: _________________________________________________________
Certifying you are an adult and over 18 years old.
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