USC Jersey Promotion - Mail Manager - Data Driven. Results Focused.

Agency Name*
Producer Code*
Agent’s Name*
Address*
City*
State*
Zip Code*
Phone*
Fax
Contact Name*
Shipping Address
- Check box if you want this shipped to your agency address listed above.
- Check box if you want this shipped direct to your Customer, then provide their details below.
Customer Name
Address
City
State
Zip Code
Phone
Check "YES" if you want to ship to any additional customers.
- Yes
- No
Customer Name
Address
City
State
Zip Code
Phone
Additional Shipping Address
Customer Name
Address
City
State
Zip Code
Phone
Additional Shipping Address
Customer Name
Address
City
State
Zip Code
Phone
Additional Shipping Address
Customer Name
Address
City
State
Zip Code
Phone
Additional Shipping Address
Customer Name
Address
City
State
Phone
Please provide your Credit Card information for billing purposes
Contact Email*
Credit Card #*
Expiration Month*
Expiration Year*
Security Code*
Name on Card*
Billing Address (if different from above)
City
State
Zip Code
Confirm the total # of USC Jersey/ies you want*
What size? Select how many MEDIUM*
What size? Select how many LARGE*
What size? Select how many X-LARGE*
Confirm the amount we will bill your Credit Card: # USC Jersey/ies @ $25 each*
*
- By checking this box I understand that Mail Manager, Inc. will contact me PRIOR to charging my credit card with the total amount due based on the # of USC Jersey/ies I have ordered.

Please provide your Credit Card information for billing purposes