Digital Media Services Secure Order Form

Step 1. Your Information: Please fill in all fields

Company Name:
First Name:*
Middle Initial:
Last Name:*
Email:*
Phone:* (no spaces 7327327322)
Address:*
City:*
State:*
Zip:*

Step 2. User Information: choose a username and password. Information is CaSe sensitive.

User Name:*
Password:*
Confirm Password:*

Step 3. Select a State:
Select State:* To select multiple states hold control key down and click on the states you would like to subscribe.
You will be billed per state.

Step 4. Payment Information: (select a payment option)

Yearly:     (You will be billed one payment of $199.00)
Bi-Annual:     (You will be billed $105.00 each half year)
Quarterly:     (You will be billed $55.00 each quarter)
Monthly:    (You will be billed @$20.00 per month)
Monthly Subscribers select how you would like to be billed.

Step 5. Credit Card Information: Credit Card Policy

Card Type:
Card Number:*
Name On Card:*
SIC Number:*
Expiration Month:*
Expiration Year*

You are agreeing to a contract.
By typing your signature you will enter into a legally binding contract to purchase the item from the seller.

Sign Here I agree to all terms set forth.