Giant Johnson - Fax Order Form

Giant Johnson - Fax Order Form

Please print this form, enter the required information and fax to:

Austin Research Order Processing Department
(410) 374-8087

COST FOR MEMBERSHIP

  The cost for complete online access to the 3 different sites from Giant Johnson
  is just $ 98.00. This is a one-time cost.

BILLING INFORMATION

  FULL NAME: ____________________________________________________

  BILLING ADDRESS: ______________________________________________

  CITY, STATE, ZIP: _______________________________________________

  COUNTRY/PROVINCE: ___________________________________________

  TELEPHONE NUMBER: ___________________________________________

  Note: Billing name and address must match the information on your credit card account exactly or it may not be accepted.

FULFILLMENT INFORMATION

  NAME: ____________________________________________________

  EMAIL ADDRESS: ____________________________________________

  EMAIL ADDRESS (REPEAT): ____________________________________

  Note: Your information will remain completely confidential and will not be sold or given to anyone.

CREDIT CARD INFORMATION

  SELECT CARD TYPE:             VISA     MASTERCARD     DISCOVER     AMERICAN EXPRESS

  CREDIT CARD NUMBER: ________________________________________________________

  CARD EXPIRATION DATE: (month/year) ___________________________________________

  CVV2 or CID (3 or 4 digit security code): __________________________________________

   IMPORTANT: THE SECURITY CODE IS A REQUIREMENT. WE MUST HAVE THIS CODE IN ORDER TO PROCESS YOUR ORDER.

   VISA/MC/DISCOVER:  Visa, MC and Discover all use 3 digit codes located on the back of the card, following the credit card number.
   AMERICAN EXPRESS: American Express uses a 4 digit code located on the front of the card, separate from the credit card number.

  ORDER AMOUNT:                                                                  $ 98.00

  TOTAL AMOUNT: (order amount)                $ ___________________________

CUSTOMER AUTHORIZATION

I hereby certify that I am the authorizing card holder of this account. I understand that I will be billed for the total amount calculated above. I understand that the name appearing on my credit card billing statement will be either "Austin Research Institute via InternetSecure" or "PAYPAL AUSTINRESEA".

  CARDHOLDER SIGNATURE: ___________________________________________

  This text must be present on order form:

PLEASE FAX THIS COMPLETED FORM TO (410) 374-8087

Your access to each site will be e-mailed to you immediately upon credit card approval. Thank you.