Name:_____________________________________
Address:___________________________________City_______________State_AR_Zip_________
Phone*: Home:________________Work:___________DOB: _________
Credit card (circle one): Visa MC AmEx Disc* No:___________________________* Exp___/____
Soc Sec No. __________________________________  
Customer Signature:_________________________________________
(Rep. name/address: Max C. Standridge, 223 N. Taylor, Apt.1A, LR,  AR 72205  phone 501-666-0270 AR LIC# #98264)
*(Customer must produce valid major credit card # and Social Security Number for credit check, and be available via telephone.) 
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	  		Max Standridge
		    c/o ADVANCED SECURITY, INC.	
			6917 Geyer Springs Road, #1N
			Little Rock, Arkansas     72209


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