SCOTT CITY EASY TO READ DIRECTORY Sign Up Form

FOR CELL PHONE NUMBERS ONLY

CUSTOMER INFORMATION
First Name*

Last Name*

Billing Address
Address Line 1*

City, State, Zip:*

Published Address (Optional)
Address Line 1

City, State, Zip:

Would you like your Cell Number listed? (First Cell Number listing is $5.00)
YesNo
Cell Phone Number*:
Name you want with Cell Phone Number*:
Each additional cell number is $2.50/each, Please list any other Cell Numbers and Names you want listed (separate with a comma).

How many Scott City Easy to Read Directory books would you like? (Books are $15.00 each)

Contact me to list my business
Yes, Contact me
What is your Contact Number and address?


Yes, I Agree: By filling out and submitting this form I agree to have my cell number published in the Scott City Easy to Read Directory.
I understand that the cost for the first cell number is $5.00 and $2.50 for each cell number I request to be published after that.
Each Easy to Read Directory that I request is $15.00. Statements will be sent out after the books are distributed.

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