Please print and complete the New Media Distributorship Application Form below, and then mail or fax it to the address / fax number indicated on the form. Retain a copy for your records.
If you prefer, an original application form can be mailed to you instead. E-mail us (with your complete mailing address) at PhoneCard4u@juno.com, and we'll send the form to you right away!
You will receive your new distributor package in 4 to 6 weeks after you submit the application.
Name___________________________________________ Date__________________
Address________________________________________________________________
Address________________________________________________________________
City__________________________________ State_______________ Zip___________
Phone__________________________________________________________________
FAX____________________________________________________________________
E-Mail__________________________________________________________________
PAYMENT METHOD:
[__] Check [__] Money Order [__] AmEx [__] Visa [__] Mastercard [__] Discover
Credit Card Number_______________________________________________________
Expiry Date: _______________________ Signature_______________________________
| PRODUCT NAME | Qty | Cost Ea. | Total |
| The Start Up Package | ______ | __$195__ | _______ |
| The Executive Package | ______ | __$295__ | _______ |
| The Premium Package | ______ | __$495__ | _______ |
| Subtotal | _______ | ||
| Local Sales Tax | _______ | ||
| Shipping | _______ | ||
| Total | _______ |
Add local sales tax for ( CA, UT, NB )
Shipping & Handeling $9.00 per package. ( UPS Ground )
All Packages as described here are subject to terms and conditions of the service agreement.
Please mail or fax this form to:
New Media Telecommunications, Inc
P.O Box 12109
La Jolla, California 92039-2109
FAX (619) 558-3344