Please fill out the information as it should appear on the card. We recommend that you enter your name as it appears on your passport. 1.Card Information Title Mr Mrs Ms (required) First Name(required) Last Name(required) Date Of Birth Date Of Birth(month) Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec (required) (date) Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 (required) (year) Year 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 (required) 2.Mailing Addresss First Name(required) Last Name(required) Address 1(required) Address 2 City(required) State ALABAMA (AL) ALASKA (AK) AMERICAN SAMOA (AS) ARIZONA (AZ) ARKANSAS (AR) CALIFORNIA (CA) COLORADO (CO) CONNECTICUT (CT) DELAWARE (DE) DISTRICT OF COLUMBIA (DC) FEDERATED STATES OF MICRONESIA (FM) FLORIDA (FL) GEORGIA (GA) GUAM (GU) HAWAII (HI) IDAHO (ID) ILLINOIS (IL) INDIANA (IN) IOWA (IA) KANSAS (KS) KENTUCKY (KY) LOUISIANA (LA) MAINE (ME) MARSHALL ISLANDS (MH) MARYLAND (MD) MASSACHUSETTS (MA) MICHIGAN (MI) MINNESOTA (MN) MISSISSIPPI (MS) MISSOURI (MO) MONTANA (MT) NEBRASKA (NE) NEVADA (NV) NEW HAMPSHIRE (NH) NEW JERSEY (NJ) NEW MEXICO (NM) NEW YORK (NY) NORTH CAROLINA (NC) NORTH DAKOTA (ND) NORTHERN MARIANA ISLANDS (MP) OHIO (OH) OKLAHOMA (OK) OREGON (OR) PALAU (PW) PENNSYLVANIA (PA) PUERTO RICO (PR) RHODE ISLAND (RI) SOUTH CAROLINA (SC) SOUTH DAKOTA (SD) TENNESSEE (TN) TEXAS (TX) UTAH (UT) VERMONT (VT) VIRGIN ISLANDS (VI) VIRGINIA (VA) WASHINGTON (WA) WEST VIRGINIA (WV) WISCONSIN (WI) WYOMING (WY) ----------------------------------- Armed Forces Africa (AE) Armed Forces Americas (AA) (except Canada) Armed Forces Canada (AE) Armed Forces Europe (AE) Armed Forces Middle East (AE) Armed Forces Pacific (AP) (required) Zip Code(required) Phone(required) Email(valid email required) 3.Payment Information Card Type VISA MasterCard American Express (required) Card Number(required) 3 or 4 digit Security Number(required) Expiration Date Expiration Date(month) Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec (required) (year) Year 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 (required) Billing Address Details: Billing Address same as Mailing Address Address 1(required) Address 2 City(required) State ALABAMA (AL) ALASKA (AK) AMERICAN SAMOA (AS) ARIZONA (AZ) ARKANSAS (AR) CALIFORNIA (CA) COLORADO (CO) CONNECTICUT (CT) DELAWARE (DE) DISTRICT OF COLUMBIA (DC) FEDERATED STATES OF MICRONESIA (FM) FLORIDA (FL) GEORGIA (GA) GUAM (GU) HAWAII (HI) IDAHO (ID) ILLINOIS (IL) INDIANA (IN) IOWA (IA) KANSAS (KS) KENTUCKY (KY) LOUISIANA (LA) MAINE (ME) MARSHALL ISLANDS (MH) MARYLAND (MD) MASSACHUSETTS (MA) MICHIGAN (MI) MINNESOTA (MN) MISSISSIPPI (MS) MISSOURI (MO) MONTANA (MT) NEBRASKA (NE) NEVADA (NV) NEW HAMPSHIRE (NH) NEW JERSEY (NJ) NEW MEXICO (NM) NEW YORK (NY) NORTH CAROLINA (NC) NORTH DAKOTA (ND) NORTHERN MARIANA ISLANDS (MP) OHIO (OH) OKLAHOMA (OK) OREGON (OR) PALAU (PW) PENNSYLVANIA (PA) PUERTO RICO (PR) RHODE ISLAND (RI) SOUTH CAROLINA (SC) SOUTH DAKOTA (SD) TENNESSEE (TN) TEXAS (TX) UTAH (UT) VERMONT (VT) VIRGIN ISLANDS (VI) VIRGINIA (VA) WASHINGTON (WA) WEST VIRGINIA (WV) WISCONSIN (WI) WYOMING (WY) ----------------------------------- Armed Forces Africa (AE) Armed Forces Americas (AA) (except Canada) Armed Forces Canada (AE) Armed Forces Europe (AE) Armed Forces Middle East (AE) Armed Forces Pacific (AP) (required) Zip Code(required)