Call A Captain

Mail-In Sign-Up Form

If you prefer not to use a credit card, please mail your check with the following information to Call A Captain at 72 Woodman Road, S. Hampton, NH 03827.

Your Name:

Email Address:

Last FOUR digits of your Social Security #:

Address:

City:

State:

________

Zip Code:

__________

License Number:

Terms of Commitment (Please check one)

[90 days - $75]		[180 days - $ 140]
[270 days- $205]		[360 days - $270]

Initial set up fee:

$25.00

Renewal Fee (if applicable):

$25.00

Amount Paid:

$___________

Method of Payment:

Check

If paying by check, please make payable to: Call A Captain

Credit Card:

MASTER		AMEX
DISCOVER		VISA

Card Number

Expiration Date

Signature

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