Cottage Catering

Membership Enrollment

Pharmaceutical Rep Club

  Please Print and make sure to fill in all information unless specified optional.

  Company:__________________________________________________

  Members Name: _____________________________________________

   Home Address: _____________________________________________

  City/State/Zip: _____________________________________________

  Work Phone #:_____________________________________________

  Cell Phone #: _____________________________________________

  Email Address: _____________________________________________

  Birthday: __________________________________________________

  Fax # (optional):_____________________________________________

  Would you like us to confidentially keep your credit card number on file?

 _____ YES, Info Below _____ YES, Please Call Me _____ NO

  Name on Card (if not your):___________________________________

  Credit Card Type:__________________________________________

  Credit Card #: ____________________________________________

  Expiration Date: _________________________________________

  Billing Address:(if different from above)

  Street_____________________________________________

  City__________________________State____________Zip____________

Thank you, and Congratulations on becoming a member of

Cottage Catering’s Pharmaceutical Rep’s Club.

And as a special gift for becoming a member today you will receive

  25% off your first order. 15% off second and 10% off your third order.

 (To get the three discounts you need to use them all withing 30 days of your first order)

(Current reps get 25% off next order just for filling out the form)

FAX TO 504-218-4196

&

START RECEIVING YOUR BENEFITS NOW!