Virtual Media Works   (RepSource Membership)

112 Leacock Road, Montréal, Quebec, H9R 1H1   Canada

PAY BY REGULAR MAIL:  Back to secure online payment form

____ RepSource Membership: 3 month RepSource Membership  $ 27.95 US funds

____ RepSource Membership: 6 month RepSource Membership  $ 47.95 US funds

____ RepSource Membership: 12 month RepSource Membership  $ 77.95 US funds

Select the following payment option:

                 Regular Mail:  Please print this sheet and complete the fields below.
                Please ensure to PRINT and to include all the information requested.

Your company name:  __________________________________________

Your name: __________________________________________________

Your email:  _______________________________________________

Phone number: ____________________

Signature:  ____________________________________________________________

Make your check Payable to:  Virtual Media Works

MAIL PAYMENT TO:

112 Leacock Road, Montreal, Quebec, H9R 1H1, Canada

Upon receipt of this payment  by mail our representatives will contact you by email and provide instructions for

the completion of your order.

Email inquiries:   support@vmwinc.com      RepSource Home Page:   www.vmwinc.com/repsourcehome.htm