Home Acceptance Form Registration Form W-4 Form

PLEASE CIRCLE 3 TYPES OF TV SHOWS YOU LIKE!
DRAMA ACTION FAMILY
HORROR SOAPS THRILLER
COMEDY KIDS SPORTS
MUSIC NEWS POLITICS

PLEASE CIRCLE 3 TYPES OF MUSIC YOU LIKE!
COUNTRY DANCE HIP HOP
GOSPEL KIDS LATINO
METAL POP R&B-SOUL
ROCK RAP REGGAE

YOU MUST REGISTER BY THE NOVEMBER 8,2008 TO RECEIVE THE $350 SIGN ON BONUS! AND YOU MUST SEND IN THE W-4 FORM TO GET PAID!

Registration Form

Please Provide Our Company With The Address Where You Will Receive Your Materials!

Name:_______________________
Address______________________
City_________________State____
Zip:____________

I am paying by:

( ) Cash ( ) Money Order
( ) Visa ( ) MasterCard

For Credit Card Orders:

Card Number_________________
(15 or 16 digits) Signature Code______
Telephone Number_____________
Card Expiration Date___________
Name of Cardholder__________________

( )Television Monitor Program $12.95
( ) Music Monitor Program $12.95
( )Both Programs $19.50


BNH INTERMEDIA
5380 W. 34th STE.162
Houston ,Texas 77092

**** NOTE YOU MUST REGISTER BY NOVEMBER 8,2008 TO RECEIVE THE $350 BONUS ****
Home Acceptance Form Registration Form W-4 Form