Self Reliance Membership Rapid Enrollment Form

Front Sight Self Reliance Lifetime Membership

Yes Dr Piazza, I'd like to take advantage of your Self Reliance Lifetime Membership. I understand this is an individual membership that I'm being allowed to purchase at a significantly reduced cost.

The Self Reliance Membership Includes the following benefits:

Self Reliance Lifetime Membership In Three Easy Payment Options 

90 monthly credit card payments of $39 for a total cost of $3,510.   OR

60 monthly credit card payments of $49 for a total cost of $2,940 (You Save $570OR

Single payment of $1,499 (You Save $2,011!)   

SPECIAL BONUS! If you are among the first 500 people to purchase a Self Reliance Membership with a single payment, I will give you a FREE Bonus, Self Reliance Lifetime Membership! That's a 2 for 1 Bonus (or $750 per membership!) If paying with single payment, enter the Name (or "To Be Determined") for the bonus membership: ____________________

Your Name:________________________________________________________________

Address:
__________________________________________________________________

City: ______________________________________ State: _______ Zip Code: ___________

Home Phone: __________________________ Work: _______________________________

Credit Card Number: _____________________________________ Expires: _____________
(VISA, MasterCard, Discover, American Express or a combination of cards for the single payment)

Signature: ______________________________________________ Date: _____________

Fax Your Rapid Enrollment Form Immediately to 707.837.0694
If Paying By Check, Mail this Form to 7975 Cameron Drive, #900, Windsor, CA 95492
If You Would Like to Enroll and Have Questions, Feel Free to Call Us at 1.800.987.7719