Customer
Information Fields
marked with an asterisk
are required input fields.
First
Name *
Last Name *
Company *
Address
*
Address
2
City
*
State
or Province *
Postal
Code (ZIP) *
Country
*
Telephone
Number *
Fax Number *
E-Mail Address *
Choose a User
Name
User
Name
Choose a Password
Password
Verify
Password
Important Note: User Name and Password are case-sensitive. Record your chosen User Name and Password exactly as entered above and store in a safe place. You will need them in order to gain access to each new issue of Creative Leisure News.
Method of
Payment Please
be sure to select your payment method
Pay by credit card *
Name
on card *
Card Number *
Expiration
Date *
Billing
Address *
Billing
Address 2
City
*
State *
Zip
*
Pay by check *
Make
check payable to:
Creative Leisure Communications
2677 Ashley Ct.
Tremont, IL 61568
Please send me a bill *
Your account will be activated upon receipt of payment.