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Laser Tag Affiliate Membership Application

Please take the time to complete all information associated with your organization. Please note that the Shipping Address is where you have large packages hand delivered (CAN NOT be sent to a post office box), and Mailing Address is where you have small mail sent (can include a post office box). Each individual member listed must include phone and email information for database and membership login purposes. Dues: $99 per year for membership. Due annually on January 1. Two contact names allowed per company.

Benefits

RSA Laser Tag Members are entitled to: Participation in the RSA Pepsi National Program that consists of a $500 Sign-on Bonus, annual rebate check for $1.90 back per gallon, plus additional promotions and programs available throughout the year!


To join as a Laser Tag Affiliate Member, complete the contract below and return to the RSA office. To complete the official RSA Pepsi National Contract, call 317-347-2626 Ext. 102 or email [email protected]

Company Information

Name of Business *
Physical Address (No P.O. Boxes) *
City *
State *
Zip Code *
Shipping Address *
(NO P.O. BOX ADDRESSES. This is where large packages should be sent or signed for.)
City *
State *
Zip Code *
Mailing Address *
(Can include PO Boxes. This is where small mail items should be sent.)
City *
State *
Zip Code *
Public Phone *
Best Phone or Cell Phone (non-published) *
Email (DO NOT use role addresses such as [email protected], [email protected], etc.) *
Fax
Website *
Name 1. (Incl.) * Title *
Personal Email * Direct Phone / Cell Phone *
Name 2. Title
Personal Email Direct Phone / Cell Phone

Payment


Total Due Today: $99.00

Credit Card Type *
Credit Card Number *         
Name On Card
Security Code
Valid Through
Credit Card Address 1
Credit Card City
Credit Card State
Credit Card Zip
Credit Card Phone Number
Credit Card Email Address
Please click submit only one time.  The transaction may take several seconds.

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