JAXPLUS

MEMBERSHIP FORM

Date: ________________________

Your Full Name: ___________________________________________________________

(This is how your name will appear on your Membership Card)

Address: __________________________________________________________________

(Where you would like your Membership Card sent)

Email Address: _____________________________________________________________

(Email address will only be used to confirm prizes and Membership Status)

Directions:

Please send this Form along with a Check or Money Order for $10 payable to JAXPLUS. Send to:

JAXPLUS

4446-1A Hendricks Ave. #217

Jacksonville, FL 32207

Make a copy of this Form for your records. You will receive your JAXPLUS Membership Card within (5) Business days. Upon receipt of your Membership Card, please make sure you log on to JAXPLUS.net and Click the green “Active Card” Tab to Activate your Member # and identify your Referral Source. Your email address and Member # will be your identity with JAXPLUS.