SPACEBOXTV.com Distributor Ship Form

4215 Spring St. suit 120, La Mesa, CA. 91941
Phone. 619-222-2525 or 1800-995-8595 Fax. 619-222-3254


Full Legal Name _________________________ [ ] Male [ ] Female

Date of Birth _______/_______/_________

Social Security No.________________________

Address ______________________________________________________

City__________State ____________Zip Code __________

Home Phone __________________Office#____________

Fax Number _______________CELL#________________

E-mail______________________________________________

$20 Member#_________( Watch videos & vote for winners - Non refundable.)

Recruiter Name_____________________ number of recruiter __________

Method of payment

[ ] Money Order / [ ] Cashiers Check,

[ ] Personal Check #_________________________ Band routing #________________

Credit Card: [ ] Visa, [ ] MasterCard

Credit Card Number___________________________________

Expiration Date ____/____/______

Cardholders name as it appears on card (print) _________________________________

Security #________ (3 digits on back of card, next to signature)

All these network positions and are paid areas, chose your position today.

Signature __________________________________Date____________

(CHECK ALL BOXES THAT APPLY)

(1) $49.99 Student, 100 word text and two debit cards, 1 video page 1 bottle of space juice [ ] $________

(2) $99.99 Teachers 2 30 minute videos plus commission 2 debit cards, 1 bottle space juice [ ] $________

(3) $399 Teacher aid teacher spot 10 video spots plus commission 10 debit cards 10 bottles of space juice [ ] $______

(4) PRINCIPLE $1995 /50, 30 minute videos /20 debit cards/ month 40 bottles space juice, one 42 inch flat screen Hitachi TV. [ ] $________

(5) Café owner / coffee / smoothies / health products / café machine / 50 computers / software school/ forty languages school / patented for models/ video games & tutor children / debit card platform to send money world wide. [ ] $_______

(Add Up all Items checked and fill in below)

SUB TOTAL IN US DOLLARS $ ____________

CALL NOW for more details
1-323-525-0005
619-222-2525

E-Mail
spaceboxtv@yahoo.com