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Shattered Productions - PO BOX 114046 - North Providence, RI 02911
Make all checks or money orders payable to Shattered Productions

DISCLAIMER
 By signing this form, I certify that I am at least 18 years old. I am aware that you are providing me with ADULT oriented material which is only for my use and will not be resold or in any way be redistributed, especially to minors.

PLEASE PRINT CLEARLY
 

PURCHASER:

FIRST NAME_________________________________LAST NAME____________________________________

ADDRESS_______________________________________________________________________________

CITY______________________________________________STATE________________ZIP______________

E-MAIL_________________________________________________________________________________

SIGNATURE______________________________________________________________________________
(Required for Disclaimer. Without this we cannot process your order)

SUBSCRIPTIONS

_____$12.99 for 1 Month of Access


_____$35.99 for 3 Months of Access


_____$65.99 for 6-Months of Access
 

PAYMENT METHOD - PLEASE CHECK ONE

    ______PERSONAL CHECK ENCLOSED

______MONEY ORDER ENCLOSED

______CASH  ENCLOSED

Once your payment is received, your Username & Password will be emailed to you.

Please print your email address clearly!