Application Form

SPECIAL NAIS Member Sign-up

Plan:  $150 for one year for either link or hosting, payment due at start.

You must either be a current NAIS member or you can

Join NAIS now

Any questions email us at:  joseph@cibir.net or pimall@alltel.net

Name: ____________________________________________________________________

Company: _________________________________________________________________

Address: __________________________________________________________________

City: _________________________________ 

State: _____________ Zip: __________

Company Phone: __________________________ 

Company Fax: _____________________________

Please choose what type of service you wish by circling your choice

For Hosting 
(PI Mall hosts your site as well as linking it):

Provide the name the you have ALREADY registered with Network Solutions or other Website registration site:

_________________________________________________

For Links ONLY:  
(Your site is already designed and hosted by another, you would like a link inside the PI Mall)

Provide your current web address:  

_________________________________________________

Please provide your Email Address: 

______________________________________________________________

Section you wish to be in:
(Please circle applicable categories)

               PI                     INFO-BROKER                             STORE 

CREDIT CARD PAYMENT INFORMATION

THE PI MALL CHARGES YOUR CREDIT CARD ON A BI-MONTHLY BASIS

THESE CHARGES WILL BE DONE AS CIBIR.

PLEASE PROVIDE THE INFORMATION ABOUT THE PERSON THE CARDS NAME IS IN

Credit Card Type:   _______________________________________

Credit Card Number:  ____________________________________________

Expiration Date:  ____________________________________

Name on Credit Card ____________________________________

Billing Address:   _____________________________________________

Billing Address City   ______________________________________

Billing Address State/Zip   _______________________________________

Billing Phone number:   _____________________________________________

I/We understand that the Credit Card listed above will be charged on a bi-monthly basis by PI Mall LLC and that the charge will be based on the Plan chosen above.  It is my responsibility to cancel my service and that the last charge will be for the month that I cancel my membership.  If I forget about my charges and report the charges as false, I understand I will be charged an additional $50 per report.  It is MY responsibility to notify PI Mall LLC/PI Mall that I wish to cancel the service.  Email can be sent to: pimall@cibir.net

Authorized signature:  _________________________________________________

Date:  ____________________________________

YOU MUST SEND A COPY OF YOUR PI LICENSE WITH THIS. NO SITE WILL BE PLACED IN THE PI MALL WITHOUT YOUR PI LICENSE. IF YOUR STATE DOES NOT REQUIRE A PI LICENSE THEN YOU MUST INCLUDE A BUSINESS LICENSE. IF NONE ARE PROVIDED, YOUR SITE WILL NOT BE ADDED TO THE PI MALL.

NAIS Member Plan:  $150 a Year

Additional Information

I, We, understand that payment will be made on the first of each month. The PI Mall will bill us starting at the end of the first month. If we wish to end out PI Mall site, all bills must be paid in full. All payments for service in The PI Mall are due upon receipt, and if payments are not received within 20 days of the date of the invoice, Web service will be discontinued until payment is received.  There will be a $25 charge for any returned checks, $50 fee for false reporting of credit card charges.  I, We, website administrators, or others connected with my website understand that canceling the website must be faxed to the offices of PI Mall LLC or sent in writing to PI Mall LLC/PIMall.  Until that time, I, We understand that we will be charged for the website.

In the event that credit is extended, and there is default of payment of sums due hereunder and if the agreement is placed in the hands of an attorney at law for collection, I, We, agree to pay all costs of collection including, but not limited to, a reasonable attorney's fee.

I, We, Our, My heirs, beneficiaries, devisees, legatees, administrators and assigns further agree to indemnity and hold harmless The PI Mall, PI Mall LLC Corporation and/or its independent contractors and employees from any and all actions, causes of actions, claims, damages and demands of whatever type wherever situated arising directly or indirectly from their work or my Web page(s), either directly or indirectly which I, We, have requested above. If any portion of this agreement is held to be invalid, then the remainder shall still retain its full force and effect.

I, We, Our, My heirs, beneficiaries, devisees, legatees, administrators understand and acknowledge that all the work that PI Mall, PI Mall LLC do on my website, or links for my website in no way guarantees that my website will be listed in the top position of search engines, and in no way can PI Mall, or PI Mall LLC guarantee by any means that my website will bring in business, customers, or visitors.

I, We, understand that The PI Mall is a joint venture with PI Mall LLC Corporation and individual investors. And that by signing up with The PI Mall I, We understand that there is no guarantee, either written, verbal, or implied, of increased sales or of increased business. It is understood that these Web pages are purely a vehicle for marketing of my/our company and services.  I understand that it is my responsibility to cancel the services with PI Mall, I can call them at 706-372-1331 or email can be sent to: pimall@cibir.net

____________________________________________ 
Signature 

____________________________

Date

YOU MUST SEND A COPY OF YOUR PI LICENSE WITH THIS. NO SITE WILL BE PLACED IN THE PI MALL WITHOUT YOUR PI LICENSE. IF YOUR STATE DOES NOT REQUIRE A PI LICENSE THEN YOU MUST INCLUDE A BUSINESS LICENSE. IF NONE ARE PROVIDED, YOUR SITE WILL NOT BE ADDED TO THE PI MALL

              
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This page was updated on March 03, 2007