ALL CITIES MEDIA GROUP
MEMBER RENEWAL FORM
If either your personal or business bio is incomplete an update must accompany this renewal form.
PRINT THIS PAGE. IF PAYING BY CREDIT CARD, COMPLETE THE FOLLOWING:
Please charge my Visa/Master Card/American Express $ 500.00
CREDIT CARD PAYMENT FORM
TO:______________________
______________________
______________________
FAX NUMBER_____________
The All Cities Network (All Cities Resource) is pleased to accept Visa, Mastercard, and American Express. We cannot, however process your payment unless all information requested below is filled out properly. It must be signed and dated as well.
Please complete this form and fax it back to the All Cities fax 310. 578.0077 >> Attn: Remi Shaw
COMPANY / Personal NAME
(only if applicable)__________________________________________
NAME APPEARING ON THE CARD__________________________________
BILLING ADDRESS FOR CARDHOLDER_________________________________________
_________________________________________
(Need full street address and zip code to process)
CARD NAME (Visa, MasterCard, American Express)_________________________________
CARD NUMBER_____________________________
THREE OR FOUR DIGIT SECURITY CODE________________________________________
(AMEX = four digit on front of card above card # // VISA or MC= three digit on back above signature)
DOLLAR AMOUNT CHARGED $_________ CARD EXPIRATION DATE(MM/YY)__________
CARD HOLDER SIGNATURE AND DATE:
_________________________________ ______________________
Please mail/fax this printed page and your payment to:
All Cities Media Group
929 Howard Street
Marina del Rey, CA 90292
Phone: 310-345-7912
Fax: 310-578-0077
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