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Printable Order Form

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To apply for membership in the Independent Expression Community at ShirleyMacLaine.com by mail, please print this form, complete it and mail to:

Brit Elders
CEO - ShirleyMacLaine.com
Box 17007
Munds Park, AZ 86017

Payment by Check or Money Order
Your completed application must be accompanied by a check or money order payable to MacLaine Enterprises and must cover a minimum of three (3) months membership ($29.97, or $16.47 for seniors, overseas or student discounts).

Payment by Credit Card
We accept Visa, MasterCard or American Express. We do not accept Discover at this time. If paying by credit card, please provide your credit card name, number and billing address (if different than your mailing address) in the spaces indicated below.

Your membership fees will appear on your credit card statement as 'MacLaine Ent.'



Membership Application Form
Please type or print clearly. All information is required, except a fax number. If all required information is not complete, we cannot process your application.
  Ms:___ Mrs:___ Mr:___
First Name: _____________________________________
Last Name: _____________________________________
E-mail Address: _____________________________________
Primary Phone No: _____________________________________
Mailing Address: _____________________________________
  _____________________________________
City: _____________________________________
State: _______________
Zip or Postal Code: _______________
Country: _____________________________________
Age: _______________
Membership Term
Monthly Membership
❑ Regular Payment by Check or Money Order
$29.97 for first three months (minimum)
$ 9.99 for each additional month
❑ Discount For Seniors, Students or Overseas only
Payment by Check or Money Order
$16.47 for first three months (minimum)
$ 5.49 for each additional month
❑ Regular Payment by Credit Card
$9.99 for first month
$9.99 for each additional month
Initial Membership Term: ______ months
or ❑ Bill my credit card monthly. I understand I can cancel my membership at any time.
❑ Discount For Seniors, Students or Overseas only
Payment by Credit Card
$5.49 for first month (minimum)
$5.49 for each additional month
Initial Membership Term: _______ months
or ❑ Bill my credit card monthly. I understand I can cancel my membership at any time.
Annual Membership
With an annual membership, you get 12 months of Independent Expression membership for the price of 10 months! That's two months free!
❑ Regular $99.90
❑ Discount For Seniors, Students or Overseas only
$54.90
Credit Card Payments
Card Name: ❑ Visa
❑ MasterCard
❑ American Express
Card No.: _____________________________________
Expiration: ____________________
If you are paying by credit card and your billing address is different than your mailing address above, please complete the following:
Billing Address: _____________________________________
  _____________________________________
City: _____________________________________
State: _______________
Zip or Postal Code: _______________
Country: _____________________________________

Choose a Login Username and Password that are easy for you to remember.


Login ID (letters only)

First Choice: _______________________________

Second Choice: _____________________________


Password (can be a combination of letters and numbers)

First Choice: _______________________________

Second Choice: _____________________________

We will contact you by email to confirm your membership, and your username and password, as soon as your transaction has been approved.

Thank you!




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