BondageDivas.com
Mail-in Membership Form
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MAILING INFORMATION:
Include your Check or US $ Money Order paying
for the term you wish to join for, and mail to:
SeaSide Media LLC
529 Belleview Blvd
Belleair, FL 33756
Make all Checks and US $ Money
Orders payable to: Infinity Multimedia Corporation
US $ Money Order memberships will
be active within 24 hours of receipt of payment.
ALL Personal Checks must clear
the bank before your
membership will be activated, this may take up to 14 days.
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YOUR FULL
NAME:____________________________________________________________
STREET ADDRESS:___________________________________________________________
CITY:______________________ STATE:___________________ ZIP CODE:_____________
COUNTRY:__________________________________________________________________
PHONE NUMBER:_____________________________________________________________
E-MAIL ADDRESS (required):________________________________________________
TOTAL AMOUNT YOU OWE (In US Currency) $_________________________________
One month = $21.95 - Three months = $50.00
Six months = $80.00
- One Year = $150.00
CHOOSE A USER NAME:________________________________
(up to 8 letters/numbers)
CHOOSE A PASSWORD:________________________________
(up to 8 letters/numbers)
YOUR SIGNATURE: __________________________________________________________
Certifying you are an adult and over 18 years old.
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