Discount Divas Savings Card Application

Print out this application and fill it out. (To print, choose "print" from the "file" menu at the top of your browser.) Please PRINT CLEARLY as this form will be used to personalize your Savings Card.

You may pay with a check, money order or credit card (Visa or MasterCard only).
Please send this form with credit card information or check or money order for U.S. $15 made payable to Discount Divas to:

Discount Divas
P.O. Box 7788
Jupiter, FL 33468-7788

You will receive your card in the mail within 2-4 weeks. The card is good for 2 years.

Date: ________________________________

Name: ________________________________________________________

Address: _____________________________________________________
City:____________________________________________________________

State:___________________ Zip:___________
Phone:________________________________ Email:______________________
Payment:
Check or money order enclosed for $15
Credit Card __________________________________ Exp:______________
Signature______________________________________ Visa MasterCard


How did you hear about the Savings Card? (so we can thank them!)

Organization (list name):_______________________________________

Store (list name & location):____________________________________

Media (print or radio):_________________________________________

Discount Divas Web site

Discount Divas e-Newsletter

Other (Web site, friend, etc.)___________________________________

Yes I would like to receive the (free) Diva e-newsletter