Fax List Order Form                                          www.admaxmarketing.com
 PRINT THIS FORM

  Please check the following that you want on your list: (Only a portion of our lists contain full fields)

  ____Fax # ____Phone# ____Company Name (Not available on many lists - Call for details)


 Please indicate how you would like these files saved: (file type you prefer)

  ____.txt (text) ____.xls (excel) ____ .dbf (dbase) ____.tab (ascii) ____.csv (comma separate)


Please Detail List Requirements:

  Area Code(s) / Cities_____________________________________________________________

  Business Type(s)_______________________________________________________________
.
 

Checks. Make Checks Payable to "Petron Plus-CA". Allow 4-5 business days for checks to clear, before receiving lists. Mail to address below.
.
Credit Cards.  All information on this form must be completed.  Fax this Signed form to: 603-994-1746 

     VISA_____ MC_____ Discover_____ (check one)   ** NO AMERICAN EXPRESS

     Card Number______________________________________________________ Ex. Date________
.
     Name on Card____________________________________________________________________

     C.V.V. # (required) ___________ (3-digit verification number in reverse italics on the back of your card)
.
     Billing Address_____________________________________________________ ST____ Zip_____
.
     Phone Number_________________________ Fax Number ________________
.
     Email address to receive list_____________________________________________


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List Order Form - Page 2


I authorize AdMax Marketing (dba Kangen Wellness) to debit my account for the purchase amount indicated
above.  I understand that I understand that these lists are non-refundable once I have taken possession.  I agree to waive the requirement for a physical signature confirmation of delivery, if receiving my list via email.  I understand that advertising response rates vary due to many factors, and that AdMax Marketing can not; therefore, does not guarantee sales or response.
.
I agree here to waive the requirement for a physical imprint of my credit credit, as I'm making this purchase from my home or office, via facsimile machine.

______________________________________________________________________________________
CARDHOLDER SIGNATURE                                                                                    DATE

NOTE:  No credit card orders will be processed without this signed order form.
 

www.admaxmarketing.com /dba Kangen Wellness