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Email Notification Service Sign-up

Your Name	Required
Email Address	Required
Land Line Phone	Area code Phone number
Address
City
State
Zip
Cell Phone #	Area code Phone number

Email Addresses To Be Notified
You may login and update these email addresses at any time. You must list at least one email address to sign up.
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Email subject line when we send out your notice: News About A Friend notice

We will use this generic notice unless you send in your own.

This email is to inform you that I may have have passed away. I signed up with a service that sends out this notice if they have not heard from me in the last 90 days. There is always a chance this email was sent in error so you might check with the alternate contact person whose email address is ___________.

Please provide alternate contact person authorized to send our the notices.

Alternate Contact Person

Alternate Contact Person's Email

My Custom Notice

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled. We will be using your information as a Card on File to charge electronically for service.

Credit Card Information

Card Type	VISA	MasterCard	Discover	AMEX
	Other

Cardholder Name (as shown on card):

Card Number: Security Code:

Expiration Date, Month and Year (Example 11/22):

Cardholder credit card address:

Cardholder ZIP Code (from credit card billing address):

Electronic Signature, required. Date: Month and Year (Example 11/22):

Name of person who told you about our service

Email Address of person who told you about our service

I found you on the internet

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Tell A Friend About "My Death Notice"

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