Customer Information
*First Name __________________________________
*Last Name __________________________________
*Business Name ____________________________________
*Email _______________________________________
*Phone _______________________________________
Choose 3 categories you prefer your coupon to be posted in order of preference
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
Make Check or Money Order for $100.00 Payable To: Clubhouse2000
Mail Payments and Coupons to:
Clubhouse2000
14-18 Pondway
Manorville NY 11949
Business Address
Name of Business or Company ________________________________
Address _____________________________
City ______________________________________
State/Province ______________________________
Country ___________________________________
Zip/Postal Code _____________________________
Shipping Address (if different from billing address)
Ship To Name ____________________________
Address ___________________________
City _____________________________________
State/Province __________________________
Country _______________________________
Zip/Postal Code _________________________
* $100.00 is our introductory Annual Rate offered for a Limited time only.
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.
