VIRTUpix

Visual based

MARKETING

Solutions

________________

Online:

www.virtupix.net

Toll Free:

(808) 384-8219

FAX:

(808) 733-0808

HawaiiVirtualPix Self-Serve Signup & Order Form

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After completing this form, fax it to (808) 733-0808 , Attn: Client Management. Upon receiving this form, a Client Manager will create a new account for the agent (if one does not already exist) and contact the agent for confirmation.

By signing up for HawaiiVirtualPIX.com, you have agreed to the terms and conditions specified at http://www.hawaiivirtualpix.com/termsandconditions.htm.

Agent Information:

Agent’sName:_____________________________________________________   

Company Name:_________________________________________________________

Office Phone:______________________ Cell:_________________________ Phone:__________________________

Fax:___________________________

Agent’s Address:________________________________________________________

City:___________________________ State:_______ Zip Code:____________

Emailaddress:_________________________WebAddress:__________________

Credit Card Information:

Name on Card: _______________________________________________

Credit Card Number: __________________________________________

(Visa)__ (AMEX)__ (Discover)__ (Master)__ Expiration Date:______________

Billing Address of Credit Card: _______________________________________

City:___________________________ State:_______ Zip Code:______________

Type of Membership:

□ $45.00/month – individual agent

□ $15.00/month for each additional team member x _____ members = $________

□ $420.00/year – individual agent

□ $120.00/year for each additional team member x _____ members = $________

Promotional Code:________________________

*Memberships automatically renew at the end of the membership period unless you contact HawaiiVirtualPix  to cancel. Once a membership is cancelled, all tours will become inactive. Pricing for an entire brokerage may vary – please call  808-384-8219 for brokerage pricing.

I, _______________________________________________, authorize HawaiiVirtualPix  to charge my credit card for this order. Total charge: $________

Signature:________________________________________ Date:___________

Photographer’s Name:_____________________________