Customer Information
*First Name __________________________________
*Last Name __________________________________
Company ____________________________________
*Email _______________________________________
Phone _______________________________________

Thank you for ordering from The Coupon Web.
If you have any questions, please do not hesitate to contact us by phone at: 516.978.0261, or by email at: thelongislandweb@aol.com.

 Choose the category you prefer your coupon to be posted
_________________________________

Make Check or Money Order for $50.00 Payable To:
Clubhouse2000
Mail Payments to:
Clubhouse2000
14-18 Pondway
Manorville NY 11949

Business Address
Address Line 1 _____________________________
City ______________________________________
State/Province ______________________________
Country ___________________________________
Zip/Postal Code _____________________________

Shipping Address (if different from billing address)
Ship To Name ____________________________
Address Line 1 ___________________________
City _____________________________________
State/Province __________________________
Country _______________________________
Zip/Postal Code _________________________

* $50.00 is our introductory Annual Rate offered for a Limited time only.