Request for eFundraiser - BookCodex.com

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BookCodex.com Rebate Program

Request For Program Enrollment or A Preview Of How Your Website Would Appear ... No Cost or Obligation To Either!

Information taken from this form will only be used to establish your request.

1. For acceptance, you need to be at least 18 years of age. Indicate if you are: Yes

2. Please provide the following information.

Name of Business/Group/Organization requesting the site:

Type : Business Club Professional School Other - No site will be provided for an individual or a donation website.

Number of potential online shoppers, from your group/organization, that could use the provided site: Less than 50 More than 500

Name of the contact person:

Contact's phone: Contact's eMail:

Please ensure that your email filter will accept email from bookcodex@swva.net

In lieu of submitting from this web page, print this form and send to:

bookcodex@swva.net or BookCodex.com, 6702 Ferrum Mtn Rd, Callaway, VA 24067