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Become a Representative
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Please complete the form below.
SSL This Order Form is Secured by SSL Encryption.
Billing Information
First Name :
Last Name :
Address:
Address Line 2:
City:
State/Province/Other:
Zip Code/Postal Code:
Country:
Phone:
E-Mail address:
Re-Enter E-Mail Address:
Payment Method:
Credit Card      Check       Money Order
Requested Seat #:
Photo Location (Row-Column) Example: 09-20 (View Homepage)
Your Total Seat Cost is:
$50 (US)
Special Instructions:
 
Establish a Username and Password
Username:
Password (Min. 6 characters):
Re- Enter Password:
Profile Information
(This is the information that will be displayed on your 450 X 450 Pixel Profile webpage. Your Ethnic Background is for internal use only and will not be displayed to the public.)
First Name:
Last Name:
Gender:
Male Female
Are you at least 18 years old:
Yes No
I have read and agree to the TOS:
Yes No
Ethnic Background:
If Ethnic Background Other:
Country:
State/Provence/Other:
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Mousover Message Display         Supply information later:
This is the short message that will display when someone hovers thier mouse over your photo on the homepage. Maximum 40 characters in length, including spaces. (ex. Hi I'm Jim Jones from LA California.)
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Link:      Supply information later:
You may display 1 link (hyperlink) to any personal webpage, or business website that you like. The link should begin with http://
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Personal Bio:     Supply information later:
Here you can write a brief personal bio. Maximum length is 325 characters including spaces. Your Bio can fill approximatley the space provided here below.
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Business Information :     Supply information later:
Here you can write some information regarding your business. Business interest, current companies to promote, etc... (Maximum length is 325 characters including spaces)
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General Comments, Cause, Passion:     Supply information later:
Here you can write anything you like. General comments, or discuss your Cause or Passion. (Maximum length is 325 characters including spaces.)
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Upload Photo:     Supply photo later:
Here you will will browse your computer and upload your photo for the Homepage and Profile page. We will crop and re-size the photo as necessary.
Photo Upload Directions: Click on the Browse button (below). Browse to your photo image file on your computer. Select the image you would like to upload, and click Open. Then click on the Submit button on our order form. (Please Note: Photos must be .gif or .jpg format only and Max 1MB size.)
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After clicking on Submit, please allow a few moments for your photo to upload and the form to process.
 
 
 
Payment Types:
We Accept Mastercard / Visa
Check or Money Order
 
 
 
   
 
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