I certify that in using a shared computer at the above address, that I will keep my log in information and password private and confidential, per the ClubShop Rewards' "Abuse & Fraud Policy".

Fax this form along with a copy of a picture ID (driver's license or passport) to 941-475-4081 or mail the form to ClubShop Rewards, Attn: Membership Dept., 2828 S. McCall Road Suite 13, Englewood, FL 34224, USA