MAIL IN PAYMENT FORM

Name:       ________________________________

Address:    ________________________________

City/St/Zip: ________________________________

Phone:       ________________________________

Ethan Interactive, Inc.
Out In Green Bay Member Processing
Two Miranova Place - Suite 320
Columbus, OH 43215-7050
http://www.outingreenbay.com
614-298-0422 Fax

Please upgrade my membership to:
  (+) Member 7-Day Trial $6.95 
Please note: Echeck (EFT) is not accepted for $6.95 trial membership.
(+) Member Monthly Subscription $9.95
(+) Member Quarterly Subscription $24.95

NOTICE: "SPECIAL OFFERS", OR "SPECIAL INCENTIVES" WILL NOT BE HONORED USING THIS PAYMENT FORM.
Total
$__________

(make any corrections as needed)
Username: / Out In Green Bay /

Payment Method
 Personal Check/Money Order
Payable to: Ethan Interactive, Inc.		 Echeck (EFT)
US Bank Accounts Only		 Credit Card

Credit Card
Payment

Visa/Mc/Amex

 MasterCard   Visa   AMEX  Discover/Novus

Account Number:  |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Expiration Date:  |__|__|-|__|__|

CCV Code 3-4 digits on back of card:  |__|__|__|__|
Click here for a sample of what your CCID looks like.


Echeck
(EFT) 

Savings   Checking  

Account Number:  |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Routing Number  |__|__||__|__||__|__|__|__|__|

Bank Name: _________________________________________
Drivers' License/State ID #________________
State Issued: __________
Important Echeck (EFT) Notices: Out In America will create an electronic funds transfer (EFT) or bank draft, which will be presented to your bank or financial institution for payment from your checking or savings account. The account must be at a financial institution in the United States, and the check must be payable in U.S. dollars.

Charges will appear on your bank statement as "OUTINAMER". In the event your electronic funds transfer (EFT) or bank draft, is returned as NSF, or disputed as fraudulent, unrecognized, unauthorized or any other reason, we will turn the matter to our collections department. Collections from NSF/chargebacks will result in a service charge of $30.00 (USD) or the maximum allowed by law, which may be debited from your account using an EFT or bank draft. In the event the chargeback is not resolved in a timely manner we may turn the matter over to law enforcement agencies or other collection agencies and may result in additional fees due including but not limited to attorney's fees and court costs.

I agree that by submitting the above bank account information I hereby authorize Out In America to initiate debit entries to the bank account indicated above and further authorize my Bank to debit same to such account. This authority is to remain in full force and effect until such time as the service has terminated, or Out In America has received notification from me of its termination in such time and in such manner as to afford Out In America and my Bank a reasonable opportunity to act on it.   I further agree that I acknowledge, understand, and agree to be bound by Out In America's Terms and Conditions.

I INDICATE MY ACCEPTANCE OF THE ABOVE ECHECK (EFT) TERMS AND CONDITIONS by signing below:

Signature: ________________________________________________    Date:  ___________________

Instructions: Please allow 7-14 days for payment posting and processing.   You will be notified by email when your payment has posted, and your membership has been upgraded.  Return to Out In Green Bay