Please Print Carefully or Type 

All fields are REQUIRED.  Incomplete forms will not be processed.  Please use 
only one form per purchase.

----------------
YOUR INFORMATION
----------------

Name: _______________________________________________________________________


Email Address: ______________________________________________________________
IMPORTANT!  This is the only way we will contact you when your account has been
set up and is running properly.  PLEASE PRINT CLEARLY!!


Billing Address: ____________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

I certify I am over 18 years of age.

Signature: __________________________________________________________________

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PRODUCTS
--------

Please calculate the appropriate charges based on the number of months desired. 

BosomBox: $29.95 x ____ months = $____________TOTAL


PLEASE PRINT CLEARLY:
Desired Username: __________________________________________________________
(at least 8 characters and it is case sensitive)

Alternate: _________________________________________________________________
(in case first selection is taken)

Desired Password: __________________________________________________________

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PAYMENT
-------

Please Make Check or Money Order IN U.S. DOLLARS ONLY Payable to:

KCW, Inc
P.O. Box 17403 
Raleigh, NC  276O9

You MUST include a copy of your Drivers License or another form of picture
ID (military ID, State issued ID, etc).  You will be emailed when your account 
is set up and operating.

Thank you,

BosomBox.Com
techsupport@bosombox.com