BiggerCity Fax/Mail Subscription Form

Billing Information:
Full Name:
Address:
City:
State/Province:
Postal Code:
Country:
Email Address: (required)
Phone: (optional)
Payment:
Card Type:
Visa   MasterCard   Discover  
Full Name: (as shown in the card)
Card Number:
Expiration Date (MM/YYYY):
/
Security Code (Last 3 digits on back of the card):
Signature:
By signing, I certify that I am 18 years or older and of legal age in my country/locale of residence to access explicit adult content online. I agree to pay the total amount for the subscription service purchased.
Date of birth (Month / Day / Year):
Account Information:
Username:
  (your account sign-on name -- this account will be upgraded to Premium)
 
Note: If you don't have an account yet, you must create a free Basic account online before you send this form. No personal identifiable information will be collected during the creation of your free Basic account.  Once your subscription form is processed, your Basic account will be upgraded with the Premium subscription you select below.
Premium Subscription

Select the plan you wish to purchase:

3 Months - USD $19.95
6 Months - USD $29.95
1 Year - USD $49.95
Promotional Code?

If you have a promotional code write it below and apply the discount to your check payment (we will apply it for credit card orders):
To Submit your Order...
By Fax:
  1. Complete the form, including the credit card payment information and signature.
     
  2. Fax the form to: +1 207-761-2822
By Mail:
  1. Complete the form and sign the appropriate field above.
     
  2. If you are paying by credit card complete the payment information above, otherwise include a check or money order for the total amount.
    Note: If you live outside of the USA and you are paying by check; You must send a bank cashier's check in US$ funds and drawn in a US bank account. You can purchase this type of check at your local bank.
     
  3. Mail the form to:
     
    BCPI
    PO BOX 7612
    PORTLAND, ME 04112
    USA