Please Print Carefully or Type 

All fields are REQUIRED.  Incomplete forms will not be processed.  Please use 
only one form per purchase.

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YOUR INFORMATION
----------------

Name: _______________________________________________________________________


Email Address: ______________________________________________________________
IMPORTANT!  This is the only way we will contact you when your account has been
set up and is running properly.


Billing Address: ____________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

I certify I am over 18 years of age.

Signature: __________________________________________________________________

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PRODUCTS
--------

Choose the Model from the list below and calculate the appropriate charges. 
Please use only one form per purchase.  If you would like to make multiple
purchases, please print multiple forms.


__  Bosombox.com  $29.95 x ____ months = $____________ TOTAL
__  Bosombox2.com $29.95 x ____ months = $____________ TOTAL
__  Bosombox3.com $29.95 x ____ months = $____________ TOTAL


__ Chelsea Charms 	$29.95 1st month + $19.95 x ____ months = $_______TOTAL
__ Pandora Peaks	$29.95 1st month + $19.95 x ____ months = $_______TOTAL
__ Patty Please		$19.95 1st month + $9.95 x ____ months = $_______TOTAL

__ Maxi Mounds		$19.95 x ____ months = $_______TOTAL
__ Crystal Storm	$19.95 x ____ months = $_______TOTAL
__ Asley Evans		$19.95 x ____ months = $_______TOTAL
__ Colt 45		$19.95 x ____ months = $_______TOTAL
__ Lisa Lipps		$19.95 x ____ months = $_______TOTAL
__ SaRenna Lee		$19.95 x ____ months = $_______TOTAL
__ Plenty UpTopp	$19.95 x ____ months = $_______TOTAL
__ BB Gunns		$19.95 x ____ months = $_______TOTAL
__ Crystal Gunns	$19.95 x ____ months = $_______TOTAL
__ Teddi Barrett	$19.95 x ____ months = $_______TOTAL
__ Casey James		$19.95 x ____ months = $_______TOTAL
__ Dixie Bubbles	$19.95 x ____ months = $_______TOTAL
__ Savanna Staxx	$19.95 x ____ months = $_______TOTAL
__ Lulu Devine		$19.95 x ____ months = $_______TOTAL
__ Donita Dunes		$19.95 x ____ months = $_______TOTAL
__ Shayne Fawntanna	$19.95 x ____ months = $_______TOTAL
__ Echo Valley		$19.95 x ____ months = $_______TOTAL
__ Fantasia		$19.95 x ____ months = $_______TOTAL
__ Keisha Evans		$19.95 x ____ months = $_______TOTAL
__ Kandi Cox		$19.95 x ____ months = $_______TOTAL
__ Colette Dupree	$19.95 x ____ months = $_______TOTAL
__ Nikki Diamond	$19.95 x ____ months = $_______TOTAL
__ Letha Weapons	$19.95 x ____ months = $_______TOTAL
__ Kimberly Kupps	$19.95 x ____ months = $_______TOTAL
__ Sierra		$19.95 x ____ months = $_______TOTAL
__ Lola Lane		$19.95 x ____ months = $_______TOTAL
__ XXXena		$19.95 x ____ months = $_______TOTAL
__ Melody Foxxe		$19.95 x ____ months = $_______TOTAL
__ Heather Hooters	$19.95 x ____ months = $_______TOTAL
__ Randi Rushmore	$19.95 x ____ months = $_______TOTAL
__ Harmony Bliss	$19.95 x ____ months = $_______TOTAL
__ Ricki Raxxx		$19.95 x ____ months = $_______TOTAL

__ Kitten Natividad	$9.95 x ____ months = $_______TOTAL
__ Windy Leigh		$9.95 x ____ months = $_______TOTAL
__ Summer Cummings	$9.95 x ____ months = $_______TOTAL
__ April Chest		$9.95 x ____ months = $_______TOTAL
__ Tippi Topps		$9.95 x ____ months = $_______TOTAL
__ Misty & Tara		$9.95 x ____ months = $_______TOTAL
__ Bunny Glamazon	$9.95 x ____ months = $_______TOTAL
__ Sugar Kane		$9.95 x ____ months = $_______TOTAL
__ Honey Melons		$9.95 x ____ months = $_______TOTAL


Desired Username: __________________________________________________________
(at least 8 characters and it is case sensitive)

Alternate: _________________________________________________________________
(in case first selection is taken)

Desired Password: __________________________________________________________

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PAYMENT
-------

Please Make Check or Money Order IN U.S. DOLLARS ONLY Payable to:

KCW, Inc
PO Box 17403
Raleigh, NC 27619


Please be sure to include a copy of your Drivers License or another form of picture
ID (military ID, State issued ID, etc).  You will be emailed when your account is set
up and operating.

Thank you,

PhotoClubs.Com
webmaster@photoclubs.com