REGISTRATION FOR HIP-HOP NATION

HIP-HOP CITIZEN REGISTRATION

    First Name: 
     Last Name: 
       Company OR SCHOOL: 
Street Address:
           City: 
       State:  
   Zip Code: 
 Telephone:
           FAX: 
        E-mail: 
           URL: 

EMAIL, FAX OR PRINT THIS FORM AND SEND ONLY $9.95 TO:

RPWNETWORKS

PO BOX 14334

RESEARCH TRIANGLE PARK,NC 27709

PHONE/FAX (919) 598-9641

EMAIL:

VISA/MASTER CARD ACCEPTED

TO BEGIN ACCESS IMMEDIATELY PLEASE SUPPLY THE FOLLOWING INFO

NAME AS IT APPEARS ON CARD

BIRTHDATE OF CARD HOLDER

CREDIT CARD NUMBER

EXPIRATION DATE

PLEASE REGISTER

[IMMEDIATELY AFTER YOU REGISTER YOU WILL RECIEVE A SECRET PASSWORD VIA EMAIL TO ENTER HIP-HOP NATION]

HOME