Clippers Basketball Promotion - Mail Manager - Data Driven. Results Focused.

Agency Name*
Producer Code*
Agent/Contact Name*
Agency/Contact Phone #*
Agency/Contact Email*
Customer Name*
Customer Shipping Address*
City*
State*
Zip*
Customer Phone*
Customer Email*
Select # Basketballs*
Please provide your Credit Card information for billing purposes
Credit Card #*
Expiration Date MM/YY*
Security Code*
Name on Card*
Billing Address*
Billing Address City*
Billing Address State*
Billing Address Zip*
*
- By checking this box I understand that Mail Manager, Inc. will charge my credit card $35 per item.

Please provide your Credit Card information for billing purposes