Please Print Carefully or Type All fields are REQUIRED. Incomplete forms will not be processed. Please use only one form per purchase. ---------------- YOUR INFORMATION ---------------- Name: _______________________________________________________________________ Email Address: ______________________________________________________________ IMPORTANT! This is the only way we will contact you when your account has been set up and is running properly. PLEASE PRINT CLEARLY!! Billing Address: ____________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ I certify I am over 18 years of age. Signature: __________________________________________________________________ -------- PRODUCTS -------- Please calculate the appropriate charges based on the number of months desired. Month-to-Month Membership ThrillBang: $19.95 x ____ months = $____________TOTAL OR SAVE 33%! Three-Month Membership $39.95 for 3 months Six-Month Membership $79.90 for 6 months PLEASE PRINT CLEARLY: Desired Username: __________________________________________________________ (at least 8 characters and it is case sensitive) Alternate: _________________________________________________________________ (in case first selection is taken) Desired Password: __________________________________________________________ ------- PAYMENT ------- Please Make Check or Money Order IN U.S. DOLLARS ONLY Payable to: KCW, Inc PO Box 17403 Raleigh, NC 27619 You MUST include a copy of your Drivers License or another form of picture ID (military ID, State issued ID, etc). You will be emailed when your account is set up and operating. Thank you, ThrillBang.Com memberservices@thrillbang.com