KellyMadison.com - Become a Member by Fax

If you would like to pay for your membership by credit card via fax, please print out this page and fill in the items.

-----Please remember to sign the bottom of this page-----

Username __________________ Credit card # ____________________________________

Password __________________ Expiration date___________________________________

First name __________________ CVV2# ________________________________________

Last name _________________________________________________________________

Address ___________________________________________________________________

City _______________________________________________________________________

State______________________________________________________________________

Zip/Postal Code _____________________________________________________________

Country ___________________________________________________________________

Birth date __________________________________________________________________

I declare under the penalty of perjury to the following:

I am at least 21 years of age.

I will not exhibit this material to any minors.

I personally warrant that the material I am requesting is

acceptable and meets my community standards.

I am not affiliated with any postal or law enforcement agency.

I am not placing an order for the purpose of entrapment.

-----put your signature on the bottom of the printed pages-----

Cash or MO's are sent next day, personal checks are held for 7 to 10 days to clear.
By placing a credit card order online, you infer compliance with the above statement.

Feel free to e-mail or call once you fax to confirm that your fax has been received.


Click here to read the terms and conditions.