[EMedia


SUBSCRIPTION FORM

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You will need a forms capable browser to complete and submit this form. This form was designed for best results under Netscape. Please call 800/806-7795, or outside U.S., 815/734-1146, for more information.

This form is for credit card orders. Use separate form to be billed later or to order by check or money order.

 SUBSCRIPTION INFORMATION

EMedia Professional is a monthly publication. Subscriptions are available at the following rates (charges subject to change without notice):

Please select the type of subscription you require:

SHIPPING ADDRESS

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Last Name:           
Company Name:        
Street Address:      
P.O.Box:             
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Zip:                 
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Telephone:           
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A personal identifier is required to process your electronic subscription.
Please select the color of your eyes here , and enter the date here .

 CREDIT CARD INFORMATION

NOTE: This server is not secure. If you do not want to submit your credit card information online, please complete and submit this form but call us (800/806-7795 or 815/734-1146) with credit card information to complete your order.

VISA MASTERCARD AMERICAN EXPRESS

CARD #:
EXP. DATE (MM/YY): /

Please press SUBSCRIBE! below if the preceding information is correct. To clear the form and start over, press clear.

EMedia Professional
Online Inc.
462 Danbury Rd.
Wilton, CT 06897-2126
800/248-8466 or
203/761-1466, ext. 510
Fax: 203/761-1444

For more information email: emediasub@onlineinc.com.
(Be sure to include your mailing address and telephone number.)

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