The WBF Radio Store Registration Form The purpose of this form is to make ordering certificates easier, faster and more convenient by retaining your billing and mailing information in a secure file at the WBF Radio Store. Simply print this page, complete this form, and then fax it to the WBF Radio Store at 863.533.8546, or mail it to the address shown below. Any questions? Call the WBF Radio Store at 863.534.SAVE from 8:30am to 4:30pm, Monday thru Friday. Thank You!

Full Name: Authorized Purchasers: please list the full names of other members of your household who are authorized to order certificates using your billing and mailing information. Only include individuals who reside at the address below. Please Note: Certificates are limited to one per household per month.   MAILING INFORMATION Home Street Address:   Home Mailing Address: if different from Home Street Address   City, State, ZIP:   Home Telephone Number:   Work / Daytime Telephone Number:   Fax Telephone Number: if you wish to receive the monthly list of certificates   E-Mail Address:   BILLING INFORMATION Card Type:     please circle one      Visa          MasterCard          Debit      Card Number:   Expiration Date:  month and year   CVV Code:  (3 digits) found in the signature block   Cardholder's Name:  as it appears on the card   Cardholder's Signature:   Mailing Address: 1130 Radio Road - Bartow, Florida 33830 The WBF Radio Store is open 8:30am to 4:30pm - Monday thru Friday Telephone Orders...863.534.SAVE - Fax Orders...863.533.8546 - wwbf.com/radiostore © 1995-2007 Thornburg Communications, Inc.