NRS-ONLINE PAYMENT METHODS : SUBSCRIPTION FORM (1/1)

YOUR FULL NAME:                                                    


YOUR ADDRESS:                                                     

                                                                 
 

I, the undersigned, whose full name is printed above, agree to the terms and conditions of the NRS-Online Subscription Agreement.


                                                             
Signature                                         Date
I will pay the twenty dollar ($20) NRS-Online subscription by:

        [ ] MasterCard       [ ] Visa           [ ] AMEX
        [ ] Discover/NOVUS   [ ] Diner's Club   [ ] Check

If paying by credit/debit card please complete the following:

Name on Card:                                                            

Billing Address:                                              

                                                               

                                                               


Card Number:                                              

Card Expiration:                        

Card Holder's Signature:                                        

If paying by check or money order, please make payments payable to Sevik, Inc.

Please send the completed subscription form and any payment to:

Sevik, Inc.
Attn: NRS-Online
PO Box 19762
Seattle, WA 98109
USA

- - - - DO NOT WRITE BELOW THIS LINE - - - - - FOR NRS-ONLINE USE ONLY - - - - - - -

RECEIPT STAMP:


RECEIVED BY:                                

[ ] Account Created (#         )     [ ] Client Notified     [ ] Verified        

NOTES: