Grant Seeker Pro Inc

1057 E. Imperial Hwy

Suite # 420

Placentia, CA 92870

OR FAX TO (714) 961-1412

Affiliate62 Affiliate website setup - $499.00 (non refundable)

Cash Check Money Order Visa Master Card AMEX Discover

NAME______________________________________________________

ADDRESS___________________________________________________

CITY_________________________________STATE_____ZIP_________

CARD#_____________________________________________EXP_____

EMAIL__________________________________PHONE#____________

SIGNATURE________________________________________________

*In Order To Process a Credit Card Sale Please Ensure That You Provide The Billing Address For the Credit Card If different than Mailing Address.

* By Signing Above I Authorize My Checking Account to Electronically Debited In the Event My Personal Check Is Refused. $25.00 Returned Check Fee.