CONSUMERS PROFIT SUBSCRIPTION

I am applying as, Check one: ___ Individual ___ Business ___ Organization

Name and of individual completing form: _______________________________________

Name of Business:   _______________________________________________________

Name of Business Owner: __________________________________________________

Name of Organization:

Address: __________________________ City: _______________ State: _________ Zip

Mailing Address:_____________________City:_______________ State: __________ Zip

Phone: ( ______ )____________________Extra Phone: (______)___________________

Email address_____________________________FAX___________________________

Web Page Address________________________________________________________

Discount or Special you will Honor____________________________________________

_____Become a CSC Discount “Smart Card” Representative      # of Cards         Subtotal

                One Year Card Membership Card cost $10.00 each:     _______         _______

                          Lifetime Membership Card cost $25.00 each:       _______         _______

_____As a CSC Representative purchase set of 5 cards to resale

                                        Purchase a 5 card set for $20.00 each:   _______          _______

                                     (A Rep can resale these at $10.00 each)

______Purchase your Protected Area Contract (PAC) for $250:   _______          _______

Contact Mr. Fox for further money making details regarding PAC

_____Get paid for cards sold when you link to our web page

                                 On One Year Card you are paid $3.00 each: _______          _______

                                One Life time cards you are paid $8.00 each:  _______          _______

The buyer must identify an assigned code given to your link

_____Have us develop and Host Web Page for your business

                                                                  First year fee is $125.00:______          _______

_____Renewing Web Page succeeding years are $10.00 per month:_______         _______

                                                                      Or $100.00  per year:_______         _______

_____Purchase Special Occasion One Year Membership Cards

         The first Special Occasion  Card cost you $10.00:                _______           _______

         For additional Special Occasion cost you only $5.00 each:    _______          _______

                                                                                                 Total # of Cards    Total Cost

                                                                                                     _______          _______

Please indicate where you heard about the CSC Discount Smart Card.__________________

_______________________________________________________________________

If you learned about the card from our Web Page or another, please provide the reference

code they provided so we can give credit to the appropriate sources.

Make check or money order out to CONSUMER SAVERS CLUB.

Mail form with check or money order to:  CSC Smart Card

                                                                        Box 2922

                                                                    Lawton, OK 73502