Your Name (First and Last)*   

Your Email &/or Phone*   

(If you are a Program Sponsor, please enter the name of the sponsored person here: )

Client Name* (As it is to appear on envelope.  Example: John and Mary Smith) 

Client Street Address*  

City*   State* AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY     Zip* 

Client Mailing Info*:

Delete client    Change Name    Change Address

Add Client To:                        

            3 Year Closing Follow-Up Program:  (None) 19 Card Buyer Program 19 Card Seller/Other Program 7 Card Buyer Program 7 Card Seller/Other Program 4 Card Buyer Program 4 Card Seller/Other Program

                                    Closing Date (mm/dd/yy):

            3 Year Client Follow-Up Program:  (None) 7 Card New Client Program 7 Card Prospect Client Program

                                    Reference Date (mm/dd/yy):

            3 Year Birthday Mailing Program:      (None) Set A Set B Set C

                                      Birthdate (mm/dd/yy):     

            Sphere Mailing Program?*:               Yes No                                     

Comments:        

By submitting, I authorize Just Stay In Touch, Inc. to update my client database with the changes detailed above, and apply any applicable charges to my account..