Special  Request  Submission

complete and submit the  form herein following,
to receive priority consideration of preferences

Name --
Contact Method --

eMail       Snail Mail       Fax       Tel 

Contact Details --
 INCLUDE EMAIL, ADDRESS, AND OR FAX AND TELEPHONE NUMBERS.
Payment Method --

Cheque         Money Order         Other
Payment Details --
INCLUDE THE NAME AND ADDRESS OF THE FINANCIAL INSTITUTION YOUR PAYMENT SHALL BE THROUGH.
Payment Frequency --

Monthly         Quarterly         Annually
your precisely accurate contact information is required;  payment arrangements other than via PayPal are by special request only and acceptance thereof shall be at PRISM PORTAL's sole discretion;  to receive priority consideration in this instance, specify your reasons for requesting other than secure, on-line payment processing: