First Name:

MI: 

Last Name: 

Mailing Address:

City, State, Zip:

DOB:

Home Phone: 

Cell Phone:

Email Address:

SS#:

Memberships:  (Silver, Gold or Platinum)
Silver membership: (6 mo. term)  1 credit card $4K : cost: $800 one time payment
Gold Membership: (12 mo. term) 2 credit cards $7K ea.: cost $1800 one time payment
Platinum Membership: (24 mo. term)3 credit cards $10K ea.: cost $3400 one time payment
    Add extra $5000 to each card I ordered. cost: $300 per $5K per card one time payment
       $5000 to one card: $300
       $5000 to two cards: $600
       $5000 to three cards: $900
       Increase my one card by $5000: $300
       Increase my card by (Dollars) increase my bill by
Seasoning: trades can be seasoned for extra fee:
         Age my membership $1000

(For every $5k you want added to your card add another $300 per card.)