APPLICATION FOR PREMIUM SEARCH MEMBERSHIP-One User License ========================================================== **ALL FIELDS ARE REQUIRED** Applicant's Name: _________________________________________ Applicant's Address: _________________________________________ _________________________________________ Applicant's City: _________________________________________ Applicant's State/Zip: _________________________________________ Applicant's E-Mail: _________________________________________ Proposed Username: _________________________________________ Proposed Password: _________________________________________ Length of Membership: ()1 Year or ()90 Days Amount Enclosed: $_________ Is This a Renewal ? ________ (yes/no) Please briefly describe your intended use for this account: __________________________________________________________ __________________________________________________________ __________________________________________________________ ========================================= Please check all that apply (optional): A. I wish to become a Member because - () to avoid advertizer screens () to view "reserved" databases () to view the databases in the Work In Progress page B. I'd like to see more of these databases developed - () State Births, Deaths, Marriage & Divorces () City Directories/Phone Books etc. () other: ________________________________________________ __________________________________________________________ Please allow three weeks for processing. You'll be notified by e-mail. Mail to: The Vitalsearch Company, LLC 1894 East William Street Suite 4 Box 476 Carson City, NV. 89701