Tom Danley's "Tape of the Month" - Subscriber Application

Name:                    _______________________________

Social Security #:   _______________________________  (For tax form 1099)

Mailing Address:    __________________________

City:                       __________________________  State: ____   Zip: __________

Phone:                   __________________________

Sponsor ID: 18107 Cliff Bassett

Circle One:  Audio Tape  or  CD  . .  "Send $25 + $10 for Start-up Kit"

To Pay By Bank Draft
Please Print

THE TRANSACTION DAY WILL BE THE 27th OF EACH MONTH.

I hereby authorize Tom Danley Companies to draft the designated account below for my monthly payment of $25.00, plus a $1.00 processing fee. Add one-time $10 fee for Business Start-up Kit.

Bank Name______________________________________________________________________

Bank Routing Number (9 Digits): _____ _____ _____ _____ _____ _____ _____ _____ _____

Checking Account Number ____________________________________________________________

Signature __________________________________________ Date ____________________________

PLEASE INCLUDE A VOIDED CHECK ALONG WITH THIS FORM

Note: There is a $5.00 processing fee for bank drafts returned for insufficient funds.

To Pay By Credit Card
Please Print

Circle:   MASTERCARD         VISA

Name Card is Issued in: _____________________________________________________________

Credit Card #:  ___________  ______________  ___________  ___________

Expiration Date: ____________________________

I hereby authorize Tom Danley Companies to debit the designated credit card account for my monthly payment
of $25.00, plus a $1.00 processing fee, on the 1st day of each month. Add one-time $10 fee for Business Start-up Kit!


Signature __________________________________________ Date ____________________________

Mail this information to:

Tom Danley Companies
2850 FM 727
Jefferson, TX 75657-5734
OR
Call toll free (800) 798-0897 Mon.-Thur. 9:00 a.m.-4:00 p.m. Central Time
OR
Fax your application and check to (903) 672-2035  

Pay by bank draft, credit card, check or money order

Complete the appropriate payment form below if paying
by bank draft or credit card