COMPANY NAME:_______________________________________
CONTACT:____________________________________________
PHONE:______________________________________________
FAX:_________________________________________________
E-MAIL:______________________________________________
WEB SITE: ___________________________________________
ADDRESS: ___________________________________________
TOWN:______________________________________________
STATE:_____________________ ZIP CODE:________________
CATEGORY (FOR LISTINGS)______________________________
ANNUAL FEE (SEE SPECIAL CURRENTLY IN PLACE) $__________
PAYMENT METHOD: [ ] CHECK MAKE PAYABLE TO MERRELL INSTITUTE
CREDIT CARD PAYMENTS: [ ] VISA [ ] MASTERCARD
NAME ON CARD:________________________________________
ACCOUNT____________________________________ EXP._____
SIGNATURE__________________________________ DATE______
