SUBSCRIPTION FORM FOR INDIVIDUALS

Name and title of person completing form:______________________________________

Mailing Address:_______________City:_______________State______Zip:___________

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

Email Address_____________________________FAX__________________________

Web Page Address_______________________________________________________

____Buy a individual CSC Discount “Smart Card” Membership    # of Cards      Subtotal

                            One Year Membership cards are $10.00 each:      ______       _______

                      Lifetime Business Membership Cards $20.00 each:      ______       _______

____Purchase additional, Special Occasion One Year

                     Membership Cards.  These cards are $10.00 for the

                     First and 5.00 for each additional card you purchase:     ______       _______

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