Otoko Online Secured Order Form

Otoko Online Secured Order Form

Your IP: 38.103.63.59

Please use this form to either sign up for a membership or make payment on goods, photos, or DVDs purchased. The charge will show up as WU PHOTO/VIDEO STUDIO.
If you are not paying by credit card, please: (1) fill in your email address, (2) print out this form, then (3) click on the Submit button. Please mail payment to: Patrick Wu, 2314 Ferguson Lane, Austin, Texas 78754.
I agree not to share my username and password with anyone. I understand my membership will be canceled and no refund will be issued to me if I do.
The Greenwich Mean Time now is: Sat Sep 6 02:31:31 2008 !
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Personal Information
First Name:
Last Name:
Address:
City:
State: Zip Code:
Country: Phone:
Email Address:

Membership
$151 (360 days) $86 (180 days) $54 (90 days) $32 (30 days) $22 (3 days) $16 (1 day) $$ (photos purchased)
Photos:
Total Charge Authorized: Recurring?:

Password & User Login (for adults only access)
Desired User Login ID:
Password: solum2heels

Credit Card Information
Credit Card Type: Credit Card Number:
3-digit security code (on back of card): Expiration Date: (mm/yy)
Name on Card:
Billing Address:
Billing City:
Billing State: Billing Zip Code:
Shipping Address Information (if different from Personal)
Name of Recipient:
Street Address:
City:
State: Zip Code:


Please look over your information above carefully, and make sure it is correct before pressing the Submit button below.


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