In order to have your company's product or service approved to be added to the PediaCard™, please fill out the form below completely.
All partially completed forms will be discarded. NOTICE: All information provided is strictly confidential and NEVER released to any third parties, without your consent.

SPONSOR INFORMATION:

Type of Application: New    Update Information

My PediaCard™ Membership Number: (16-digit number on front of card)

Activation Code#: (OPT)

Applicant Information

Company Name:

First Name: Last Name:
Your Title:    
Street:
City:    
State:    Zip:
Bus Phone: 
Fax:             (OPT)
Cell Phone:  (OPT)
E-Mail: E-Mail address is required for processing.
Company Website URL: (OPT)

Product or Service Description

Product or Service: Product    Service

Please describe your product or service:



Please list the promotion and/or discount you want to offer. Please be very specific.:

Be sure to include days and times when discount is active.

May we include you in our Sponsor List for future PediaCard™ announcements and updates?

Comments or Questions:

NOTICE: Please double check all of your information BEFORE you submit the form. Your email address and phone number must be correct.