Passport America Text Registration Form Revision v1.8 2012.05.06 To complete this form, simply fill out the below information and along with your check, money order, or credit card payment in US FUNDS to: Passport America 21263 Tucker Rd. Long Beach, MS 39560-9041 USA If this is a renewal, fill in the renewal area and include your Passport America Membership ID number. Feel free to call us if you have any questions: (800) 283-7183 M-F 8AM-6PM CST, SAT 9AM-4PM. -------------------------------------------------------------------------- Date:___/___/___ Referral Number: ________________________ Name: ________________________ __New Membership OR __Renewal ID Number ______________________________ __ 1 Year $44 __Shipping (US 2-3 weeks) $5 __Check __ 2 Years $79 __Shipping (US 3-5 days) $7 __Money Order __ 3 Years $109 __Shipping (Canada 10-14 days) $13 __Credit Card __Express (US only 2 days) $19 __Shipping (Worldwide 10-14 days) $19 Name: ____________________________________________________________________ Spouse: __________________________________________________________________ Home Address:_____________________________________________________________ City: ______________________ State/Pro:_____ Zip:__________ Country:________ (If shipping address is different from permanent address): Shipping Address: ________________________________________________________ City: ______________________ State/Pro:_____ Zip:__________ Country:________ Phone: ___________________ Cell:_____________ Email:_______________________ CC #:___________________________________ Name:________________ Exp: _______ Check#: __________________ Amount: ______________ --------------------------------------------------------------------------- Fax: (228) 452-9725 Email: info@passport-america.com Website: http://www.passport-america.com - www.camp4less.com Copyright 1995 - 2012 Passport America, Inc.