Name (first and last):  _______________________________________   

Phone (w/ area code):  ( _____ ) ______ - ___________

Mailing Address: ____________________________________________________________________________________

City: _____________________________      State: ________     Zip: ______________     Country: ________________    

E-mail address:  ______________________ @ _________________________ . __________
Note: You will receive confirmation of your order by e-mail so it is very important that you provide a valid, neatly printed address.  You MUST include both your user name and email domain name in your address.  Example: username@domain.com.

MEMBERSHIP OPTIONS:

___ Clubjane.com ___Desertcuties.com ___JaneBurgess.com

___ $19.00 (30 days)   ___ $90 (6 Months)   ___ $150(1 year)

Requested user name: _________________   Requested password: _________________
Please select a user name and password combination that is easy for you to remember but hard for someone else to guess.  We suggest using a combination of letters and numbers for your password. Usernames are CaSE sEnSitIvE so be sure to print neatly.  When in doubt we will use all lower case letters when registering your user name/password combination.

I certify I am at least 18 years of age (21 in AL, MS, NE, and WY) and the ID provided is, in fact, my own. I am familiar with the laws in my country, state and county/region regarding the purchase of adult oriented web site memberships and/or merchandise and I am legally able to purchase everything ordered on this form. If ordering merchandise, I further certify that I am familiar with the postal laws where I live and it is legal for me to receive adult oriented materials. If ordering a membership I have read, agree to and understand the Terms and Conditions of membership to Desertcuties.com. I understand TannerMedia, LLC is not responsible for lost or incomplete orders and refunds cannot be provided. I accept full legal and financial responsibility for my purchases and agree to hold TannerMedia, LLC, harmless if any legal matters should arise. 

____________________________________            Date: ________________
Your Signature

Make Money Orders Payable to and Mail to:
Greg Ninke  PO Box 2845  Tempe, AZ 85280

No orders with be processed without the required information, a copy of your ID and a money order for the appropriate amount. For your privacy, we mail all merchandise ordered to the address on this form, not the address on your ID. Please send any inquiries regarding your order to custserv@desertcuties.com  Thank you, we appreciate your business.

For office use only:  RECEIVED:_________________    SHIPPED: _________________    ENTERED:_________________    EXPIRES: _________________