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Company Name

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Billing Zip Code (required)

Phone (required)

Alternate Phone

Fax

Starting Month   Starting Year

Ending Month     Ending Year  


Please select the payment amount you are authorizing us to charge your credit card at the rate if $60 for a single issue or at the rate of 50 per month for 6 consecutive months:

Credit Card (required)

Account Number (required)

Expiration Date

Month (required) Year


CVV code (3 digit code on the back of the card if it's VISA, MasterCard or Discover or 4 digit code on the front of the card if it's American Express.):

Name of Cardholder


On behalf of my company or myself, I hereby reserve the coupon space(s) and issue date(s) indicated above and authorize South Lake Tahoe Coupons to charge the credit card indicated on this form.

I agree to accept full responsibility for any losses that might incur due to this publication.

The undersigned agrees to hold South Lake Tahoe Coupons harmless for any losses or liability that might occur due to this publication.

I understand that South Lake Tahoe Coupons does not make refunds.

I agree that my liability for this contract is not waived and I agree to be held personally liable in the event that the indicated person, company or association fails to pay any part or the full amount of these charges.

South Lake Tahoe Coupons Reserves the Right to Refuse Business to Anyone.

By checking this box I agree to the above terms and authorized the above charge to my credit card.


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If you have any questions about completing this form please let us know so we can help you.

Office: 530-870-4565
Fax: 408-465-2700

 

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South Lake Tahoe Coupons
PO Box 8530
South Lake Tahoe, CA 96158