Member Information (please print)               Todays Date: ____/____/____
Member ID# |__|__|__|--|__|__|--|__|__|__|__|(Use any nine digits you would like)
SSN# or Fed ID# |__|__|__|--|__|__|--|__|__|__|__|(required)
Credit Card# (only if using to buy product) 
|__|__|__|__|--|__|__|__|__|--|__|__|__|__|--|__|__|__|__|  Exp Date ___/___ 
Name On Card:_____________________________________________________
Card Holders Signature:______________________________________________

Members Name: (First)_____________________(Initial)___(Last)_____________________
Mailing Address:(Street)_______________________________________________________
(we cannot ship to PO boxes)
(City)_________________________________(State)____(Zip)________________________
(Home Phone)____________________________  (Fax)______________________________
Initial Order(Min order 4 cartons) To use Auto-Ship, must use a credit card, put a X here>> (   )
Regular Price ---- 17.95 per Carton
Auto-Ship Price - 16.95 per Carton(Must Use Credit Card) Same Order Shipped Every Month

Flavor               Number of Cartons Ordered                                              Total    
Full Flavor              King_____001    100's_____1001       Price X Cartons = __________
Lights                      King_____002    100's_____1002       Price X Cartons = __________
Ultra Lights            King_____003    100's_____1003       Price X Cartons = __________
Menthols                 King_____004    100's_____1004       Price X Cartons = __________
Menthol Lights       King_____005    100's_____1005       Price X Cartons = __________
            Free Shipping (Hawaii and Alaska Orders Must Add 1.00 Per Carton) = __________
    First Year New Membership Processing Fee (annually after first year 9.95) =     19.95     
Optional Business Oppty Info Pack (With forms and Copy-ready ads) add 8.00 = __________
                                                               Total for this Order (Amount Enclosed) = __________

Method of Payment: Check (  )   M/O  (   )   VISA  (   )   MC  (   )   Discover  (   )   AMEX  (   )

Authorization:I have received, read and understand NATC, Inc Buyers Club Direct Marketing Compensation Plan and the BY-LAWS which are incorporated herein and made part of this agreement.  I have enclosed proof of age document (example: Copy of Drivers License).  I agree to purchase a minimum of 4 cartons per order.  If I do NOT list a sponsor below, one will be assigned to me without prejudice.
Sponsors Name: Franklin Kennamer
Sponsors ID #:   123456787
Remember to include:PROOF OF AGE For more info call (877) 805-1946 Fax# (623) 393-0134
Ordering with Credit Card Only you may Fax this order along with proof of age to this number ^

New Member Signature: X____________________________________________________
For office use only: 
Date Received ____/____/____   Invoice # __________   Auto-Ship Invoice # __________