ExoticBreasts.com Membership Form: 

U.S. Money Orders Only. 

Both this form and your money order must be sent
together for your membership to be processed.
 
Please print neatly and carefully or type 
   
       (All fields must be completed)



Name: ______________________________________________


Email Address: _____________________________________
(valid email required to send your membership information)


Billing Address: ___________________________________


____________________________________________________


Please circle your subscription length below:

                  These Are One Time Charges

		1 month  (30 days) ... $24.95

		3 months (90 days) ... $69.95


Desired Username: __________________________________ 
(6 - 8 characters. Please print neatly. Username is cAsE SenSiTive)

Alternate: _________________________________________
(in case first selection is taken)

Desired Password: __________________________________
(6 - 8 characters. Please print neatly. Password is cAsE SenSiTive)

Please Make Money Order Payable to:

        F. Ramirez
        P.O. Box 3124
        Alhambra, CA, 91803


By signing and submitting this membership form, I certify that I am at 
least 21 years of age. I understand that my username and password will 
grant me access to ExoticBreasts.com for a period of the subscription 
length circled above once my money order AND membership form is received
in the mail and processed.

Signature: ___________________________________    Date:____________