KILL CITY

ACCOUNT INFORMATION

FIRST NAME:
MIDDLE INITIAL:
LAST NAME:
EMAIL ADDRESS:	NOTE: EMAIL ADDRESSES MUST BE UNIQUE. EMAIL ADDRESSES WILL NOT BE SOLD OR USED OUTSIDE OF House of Widow. PLEASE MAKE SURE YOUR EMAIL ADDRESS IS VALID OR YOUR ORDER MAY NOT BE PROCESSED. YES! I WOULD LIKE TO JOIN THE House of Widow MAILING LIST TO RECEIVE INFORMATION ABOUT SPECIAL SALES AND NEW STYLES.
PASSWORD:	PLEASE ENTER A PASSWORD (10 CHARACTERS MAX) AND CONFIRM BELOW.
CONFIRM PASSWORD:
PHONE NUMBER:	NOTE: YOUR NUMBER WON'T BE SOLD EITHER.
Birthday: (mm/dd/yyyy)

NOTE: PLEASE VERIFY THAT BILLING AND SHIPPING INFORMATION IS ENTERED IN THE FIELDS BELOW AND THE INFORMATION IS CORRECT.

BILLING INFORMATION

ADDRESS 1:
ADDRESS 2:	CHECK HERE IF THE ABOVE ADDRESS IS A P.O. BOX.
CITY:
STATE:	NON USA AND CANADA CUSTOMERS PLEASE SELECT "NON APPLICABLE" FOR STATE
ZIP/POSTAL CODE:
COUNTRY:

CHECK HERE IF SHIPPING ADDRESS IS THE SAME AS ABOVE

SHIPPING INFORMATION

RECIPIENT'S NAME:
ADDRESS:	CHECK HERE IF THE ABOVE ADDRESS IS A P.O. BOX.
CITY:
STATE:	NON USA AND CANADA CUSTOMERS PLEASE SELECT "NON APPLICABLE" FOR STATE
ZIP/POSTAL CODE:
COUNTRY: