Subscription Application Form New Year Special


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New Year Special

Secure Membership 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.

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 ]

Membership Options

Membership Plan: DO YOU ALREADY HAVE A SILVER/BASIC MEMBERSHIP BUT WANT TO RECEIVE THE BENEFITS OF THE GOLD MEMBERSHIP? YOU CANNOT UPGRADE YOUR MEMBERSHIP FROM SILVER/BASIC TO GOLD ONLINE. WE WILL BE ABLE TO HANDLE YOUR UPGRADE FOR YOU IN OUR OFFICE. PLEASE EMAIL US AT: SUPPORT@AUTISMFAMILYONLINE.COM TO TELL US WHAT YOU WANT TO DO Subscription Security is povided by:	GOLD Membership - Access to the wealth of resources on AutismFamilyOnline.com including the Special Training Modules PLUS access to archives of past webinars PLUS access to the GOLD VAULT where you will be able to download webinar handouts and access certificates of participation -- handy for continuing education requirements. You will be charged $247 per year for the yearly membership. Automatic Renewal - Your credit card will be charged automatically every year. You can cancel anytime. 7 day trial for only $1 SILVER Membership - Access to the wealth of resources on AutismFamilyOnline.com including the Special Training Modules PLUS access to archives of past webinars After 7 days you will be charged $97 per year for the yearly membership. Automatic Renewal - Your credit card will be charged automatically every year. You can cancel anytime. 7 day trial for only $1 MONTHLY Membership - Access to the wealth of resources on AutismFamilyOnline.com including the Special Training Modules After 7 days you will be charged $9.97 per month. Automatic Renewal - Your credit card will be charged automatically every month. You can cancel anytime. TO UPGRADE YOUR MEMBERSHIP FROM MONTHLY TO EITHER SILVER OR GOLD To choose a different membership plan: select the new membership plan above choose "yes" in the box below in the highlighted section "Is this a Renewal or Upgrade?" time remaining on your monthly plan will be adjusted to your new plan

Choose LOGIN Name [ required ]

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

Confirm PASSWORD [ required ]

Payment Information

Payment Method [ required ]
Credit Card Number [ required ]
Credit Card Security Code [ required on (MC/Visa) ? ]
Expiration Date [ required ]	/
Name on Credit Card [ required ]
Is this a Renewal or Upgrade?
Do you wish to receive email alerts?
<<< Automatic Renewal: I understand that this membership will renew automatically (After the 7-day trial if that option is chosen) either monthly or yearly, depending on the specific member plan I have chosen, unless I cancel BEFORE the renewal date. I am free to cancel my membership at any time by following the instructions in YOUR ACCOUNT in the left menu on the home page. Also, I have read and understand the Terms of Use policy of AutismFamilyOnline.com


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