Virtual Media Works   (RepSource)

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

Fax order form:

Please select your membership below. CHECK ONE ONLY

____   Silver SALES DIVISION membership:   15 month listing in the RepSource Sales Directory      $ 89.95 US

Select the following payment option:

_________  Regular Mail:  Please remit payment as follows. Include this from with your check.
                Please fill in the appropriate sections below including your name and email address.

Check Payable to:  Virtual Media Works

112 Leacock Road

Montreal, Quebec

H9R 1H1

Canada

OR  fax your credit card order (place an X on one please)

________  Visa    

_________ American Express

_________ MasterCard

Card Number:  ______________________________________________________________

Name appearing on card:  _____________________________________________________

Expiry date on card:   _______________

Your company name:  __________________________________________

Your name: __________________________________________________

Your email:  _______________________________________________ Phone number: ____________________

Signature:  ____________________________________________________________

Upon receipt of this information by fax, our representatives will contact you by email and provide instructions for

the completion of your order.

If paying by credit card, please fax back your order to us

at :     Virtual Media Works:  (514) - 630-1421

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