Name and Membership ID number of the VIP Member(s) who will be coordinating the project (if any)

Name____________________________________ID Number____________________________

Name(s) and Membership ID number(s) of any other Members involved in this project (if any)

Name____________________________________ID Number____________________________

Name____________________________________ID Number____________________________

Quantity (number) of cards to be created. #___________________________________

Name & address of the company or organization requesting the cobranded card:

Name & Address________________________________________________________________________

_______________________________________________________________________________

Type of card to be created: Paper or Plastic (circle one)

Name & address of the company that will be doing the printing. (A copy of the contract with the printer must be submitted with this application).

Name & Address________________________________________________________________________

_______________________________________________________________________________

The per card cost to be charged to card recipients, if any. $_____________________

I declare that I am authorized, by the above named company or organization, to make application for them to co-brand the ClubBucks Rewards Card. We understand & agree that a final proof of the co-branded card must be submitted to the DHS Club for review prior to their final approval being granted.

On behalf of the company or organization, I have read, understand, and declare that said company or organization making this application agrees to abide by the Co-Branded ClubBucks Rewards Cards Terms Of Agreement.

_________________________________________________
Signature of Authorized Representative

_______________________________________________________
Date Signed

Print application. Fill in by hand.
Mail or Fax Completed form to:
The DHS Club
2560 Placida Road
Englewood, FL 34224
Fax: (941) 475-4081