To print this page properly - use Print icon located on the page.
Please note that JavaScript has to be enabled.
 Place your organization logo here
Mi Local Perks
 

     Business Member Log In Only: Log In Not Required for Shoppers:

Gold Application

Level
2 - Gold Membership ($66.00 (USD)) Subscription period: Quarterly Automatic renewal: no
To become a business member at the Gold level and to be included in the database, please complete the application form below.

Fill in application form

Application form

* Mandatory fields
 

 

*First name
*Last name
*Organization
Logo
 

Contact Data

*e-Mail
Phone
*Password
 
*Website
Address
*City
*Province/State
*Postal code
*Yes, I Agree to Terms
Name of Sales Rep (if there was one)
 

Points & Specials

*How Do I Redeem Points?
*Special #1
*Spec. #1 - Exp. Date:
Special #2
Spec. #2 - Exp. Date:
Special #3
Spec. #3 - Exp. Date:
 

Business Details

*Business Category
If other-not listed, what is your business category?
*Brief Description
*Business Summary (250 char.)
 

Billing and Payment

*Credit/Debit Card Number
*Credit Card Type
*Expiration Date
*Security Code (on back of card)
*Name as it appears on the card
*Billing Address
*City and Zip

Discount code

Enter discount code

Security check

* Code
 
Type the 6 characters you see in the picture
Captcha code image
Hear the code Try another code
Cancel
 
Content copyright 2010. Mi Local Perks, LLC. All rights reserved.
Any duplication or transmittal of copyrighted content published here at MiLocalPerks.com, without express written permission,
is considered copyright infringement and is punishable by law.