Sign me up for STAT-USA/Internet!

This form allows you to sign up for a STAT-USA/Internet account. This account is a "single designated user" account and is to be used by the indicated user named below.

Select a Product: INT1 -- One-day Internet subscription, single designated user: $25
INT20 -- Quarterly Internet subscription, single designated user: $75
INT30 -- Annual Internet subscription, single designated user: $200
Note: The STAT-USA/Internet annual subscription price increased to $200 on October 4, 2005. Quarterly subscription prices were not effected.


Payment Type:
 Check to "STAT-USA" VISA
Money Order American Express
MasterCard Discover
Credit Card Number: Note: indicates required field
Expiration Date (mm/yy): /
Name on Credit Card:
User's Name:
Organization:
Mailing Address
(Line 1):
(Line 2):
City:
Locality (e.g. State):
Postal (ZIP) Code:
Country:
Phone Number:
Fax Number:
Email Address:
Please print this Web page. Completely fill in the blanks above (either before printing it or manually afterward) and send it with payment to STAT-USA. For faxed orders using credit cards, please fax them to STAT-USA at 202-482-2164. For mailed-in orders, send this form with payment (either the required credit card information, a check, or a money order) to STAT-USA at the following address:
STAT-USA
HCHB Room 4879
U.S. Department of Commerce
Washington, DC 20230 USA

After you've printed this page, click here to return to the STAT-USA/Internet home page at http://www.stat-usa.gov