Communicate1 Template

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Personal Information

	*First Name	:	نام

	Middle Initial	:	خالی بگزارید

	*Last Name	:	نام خانوادگی

	CompanyName (Only if you own it)	:	خالی بگزارید

	*SSN / Tax ID (US Only)	:	Why is this required? خالی بگزارید

	Date of Birth	:	,


Communication Information

	Daytime Phone	:	شماره تلفن صبح ها

	*Evening Phone	:	شماره تلفن بعد از ظهر ها

	Fax	:

	*Email Address	:	آدرس ایمیل یاهو خود را وارد کنید
			(Do NOT use a Hotmail, MSN or Earthlink address as your contact address! Click Here to get a Yahoo account if you need another email address.)


Personalize your options

	Name to Show on Website and Make Checks Payable	:	First/Last Name Company Name نامی که ميخواهيد در سايت نشان داده شود (نام و نام خانوادگی / نام کمپانی) علامت بزنيد

	Format in which you want to receive Emails	:	HTML TEXT فرمت دريافت ايميلها ( تغيير ندهيد )


Choose A Password (From 4 to 10 alphanumeric characters only)

	*Password	:	*Verify Password	:
يک پسورد انتخاب نموده 2 مرتبه در اين دو محل تايپ کنيد(بین 4 تا 10 حرف یا عدد)


	Choose Your Membership Type

	$24.95 Fast Track (Includes Empowerism Subscription)
	I choose to receive 50 opt-in leads تغيير ندهيد ، تيک داشته باشد

	Basic Membership Only(60-day trial for $9.95 one-time setup fee, no subscription benefits)


Choose your Payment Method (Billed today for $24.95) در اين قسمت چگونگی پرداخت حق عضويت خود (يعني ايگولد) را تيک بزنيد

	Credit Card: (Visa/MasterCard/Amex/Discover) (If you use another person's credit card, your charge will be voided. CLICK HERE for the correct form.)

	We report all credit card fraud. The location of your computer (IP 213.176.125.74) has been logged for security purposes.

	Name on Credit Card (Not Card Issuer)	:		Credit Card Number (Numbers Only!)	:

	Expiration Date	:	/	Zip Code (where CC statements are sent)	:

	Credit Card Security Code (Please note that we cannot accept credit card transactions without a valid security code)				:	(What's this?)



	Bank Debit (eCheck): (U.S. Checking Accounts Only. 7-DAY HOLD for eCheck orders!)

	9-Digit ABA Routing (Numbers Only!)	:	(What's this?)	Name on Account (Not Bank Name)	:

	Account Number (Numbers Only!)	:	(What's this?)




	E-Gold (Does not auto-renew)			اين قسمت را تيک بزنيد

	Your E-Gold Account Number	:



	Moneybookers

	Your Moneybookers Email Address	:



	Stormpay

	Your Stormpay Email Address	:



	IntGold

	Your IntGold ID	:


AUTO-RENEWAL OPTION
	Yes, I want Auto-Renewal! (Credit cards auto-renewed for $19.95 starting the FIRST WEEK of next month; eChecks auto-renewed for $19.95 on the 15TH day of the month.)

	No, I do not want Auto-Renewal. اين قسمت را حتما تيک بزنيد