Passport America Text Registration Form
  		      Revision v1.6      2007.12.26

   To complete this form, simply fill out the below information, detach at
the dotted line, and mail this in 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 
membership number, length of time on the membership you want, and the 
amount you pay for your membership (call us if you need more information).

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Date:___/___/___                Referral Number   :_______________________

					    Name: ________________________

__New Membership
OR
__Renewal       Number:____________Years: _____________Amount:____________

  __  1 Year	$44	__Shipping (US 3-5 days)     $5	     __Check 
  __  2 Years	$79	__Shipping (outside US)      $10     __Money Order
  __  3 Years	$109	__Express  (US only) 2 Days  $17     __Credit Card

Name: ____________________________________________________________________	

Spouse: __________________________________________________________________

Home Address:_____________________________________________________________

City: ______________________ State:_____ Zip:__________ Country:__________

(If shipping address is different from permanent address):

Shipping Address: ________________________________________________________

City: ______________________ State:_____ Zip:__________ Country:__________

Phone: ___________________ Cell:_____________ Email:_______________________

CC #:___________________________________ Name:________________ Exp: _______

Check#: __________________ Amount: ______________
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 If you have any questions please call 1-800-283-7183 to speak with a 
representative. You can also email us at info@passport-america.com. We are 
always very happy to help you!

   Passport America will not release this information to anyone. It is for 
internal use only. We do not give away or sell any information to any third 
party companies.

Voice:   (800) 283-7183 
Fax:     (228) 452-9725
Email: info@passport-america.com
Website: http://www.passport-america.com - www.campsave50percent.com 

Copyright 1995 - 2007 Passport America, Inc.