MiBiz Paid Subscription Order Form

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Is this a renewal order of your paid subscription?

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Name:

* First:

* Last:

* Title:

* Company:

* Address:

* Address Type:

Suite #:

PO Box: (if applicable)

PO zipcode:

* City:

* County:

if other:

* State:

* Zipcode:

* Email:

* Website:

http://

* Phone:

xxx-xxx-xxxx

* Fax:

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* Year Company Est.:

Length of subscription:

1 year - $46

2 years - $68

3 years - $84

Billing Information

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Address:

Suite #:

P. O. Box:

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Credit Card Information:
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Expiration Date:

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* Automatic Billing Option:

* I agree to an automatic renewal of my subscription at the time of expiration. If you choose the credit card payment option, your card will be charge an annual subscription fee when your subscription expires.

Business publications audit requires the following data. Please complete the following information. All fields must be filled out to receive your FREE subscription:
Personal Identifier (required by audit bureau in lieu of your signature)

* Year of Birth
* How many people are employed at your company?
* Industry/Profession
If you chose Mfg., Services or other, please specify type.
* Education - Please Select One
* Areas of purchasing influence - Please Select All That Apply	Accounting Advertising/PR/Promotion Automobiles/Purchase/Lease Banking Building Materials/Equipment Computer/Technology Corporate Gifts Educational/Training Programs Health Benefits Legal Services Office Furniture Office Equipment/Supplies Telecommunications Equipment None of the above
* What is your company's annual sales volume?
* I give my permission to receive subscription renewals by fax from MiBiz or its fax service to the fax number I've provided on this form.
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