AssholeKingdom.com/Wild Rose Network
Membership by Mail

Please print out the following form, fill it out neatly, attach cash or money order (NO CHECKS) and mail it to:
Carol Cox
C.P. 38033
3353 Blvd. des Sources
D.D.O., QC
CANADA H9B 1Z0

   Name:           _____________________________________________________________________

   Street Address: _____________________________________________________________________

   City/Town:      _____________________________________________________________________

   State/Province: _____________________________________________________________________

   Country:        _____________________________________________________________________

   Postal Code:    _____________________________________________________________________

   E-mail Address: _____________________________________________________________________
   
   Website:        AssholeKingdom.com___________________________________________________


   Subscription Length Desired:

       30 day membership_____________ Price: $19.95 U.S. Dollars   
   
       
       1 year membership_____________ Price: $95.88 U.S. Dollars

   UserName: _________________________ (5-15 characters) | NOTE:UserName & PassWords 
                                                         |      are case sensitive.
   Password: _________________________ (5-15 characters) |      Please Print Clearly

          You will be notified by e-mail as soon as your account is activated.

I certify that I am of legal age in my area of residence to view images and text 
meant for a mature and adult audience.

Signed: ______________________________________________   Date: ________________________