Teachnology Gold Membership Fax Sign-up Form

This form should only be used if you would like your credit card be processed off-line. Please complete the form below. The cost of 1 year (12-month) membership is $29.99 (U.S. Dollars). Please allow 1 business day for your order to be processed.

Please fax this form to: (508) 349.2588

My email address is:

_____________________________________

Choose a password:

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After the form is faxed to our offices, you will receive an email confirmation when your account was successfully setup. Your credit card will be billed $29.99 (USD) at the time of account setup.

Name: ________________________________

Company/School: ___________________________

Address: ________________________________

City: ________________________________

State: ________________________________

ZIP Code: ________________________________

Country: __________________________________

Credit Card Number: ________________________________

Credit Card Expiration Date: _________________________

Credit Card Type: Circle One

American Express, Discover,

Mastercard, Visa