Subscription Application Form


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Basement Empires Membership Application Form

We respect your privacy. The personal information requested below is for use in processing your credit card, which is done with secure encryption. We never reveal, share, or sell member information. For complete details see our Privacy Statement.

Subscription Options

Subscription Plan:	Monthly Member Plan ($17.00) + Free DVD & Instant Coaching Course - Automatic Renewal - Your Credit Card will be charged automatically every month - Cancel Anytime - Charter Membership for a Limited Time Only! 6 Month Membership ($97.00) + Free DVD & Instant Coaching Course - Automatic Renewal - Your Credit Card will be charged automatically every 6 months - Cancel Anytime

Choose LOGIN Name [ required ]

Choose PASSWORD [ required ] at least six characters long, using alphas and numbers, no spaces.

Confirm PASSWORD [ required ]

Customer Information

* = Required - Must match credit card billing address!

First Name [ required ]
Last Name [ required ]
Company
Address Line 1[ required ]
Address Line 2
City [ required ]
State [ US & Canada ]
State/Province [ All other Countries ]
Zip/Postal Code [ required ]
Country [ required ]
Your E-mail Address [ required ]
Phone or Fax Number [ required ]

Shipping Information

Shipping same as billing address

Ship To First Name [ required ]
Ship To Last Name [ required ]
Ship to Company
Ship to Address Line 1[ required ]
Ship to Address Line 2
Ship to City [ required ]
Ship to State [ US & Canada ]
Ship to State/Province [ All other Countries ]
Zip/Postal Code [ required ]
Ship to Country [ required ]

Payment Information

Payment Method [ required ]
Credit Card Number [ required ]
Credit Card Security Code [ required on (MC/Visa/AMEX) ? ]
Expiration Date [ required ]	/
Name on Credit Card [ required ]
Is this a Renewal?
Do you wish to receive email alerts?
<<< Please Check The Box to acknowledge that you have read and understood our terms of use.


NOTE: It can take up to a minute to process the credit card information and obtain approval. Please do not press the submit button multiple times - doing so could cause double billing.
For the protection and privacy of our visitors and customers, as well as the security of the server, suspicious activities on our site are monitored, tracked and reported.