AdorationPro Sign Up Form (EA)

Use this form if you are a referral from www.perpetualeucharisticadoration.com

Organization Name
(Only the main name is needed. You do not need include "parish, school, church, chapel", etc.
Example: St. Mary's)
Name of Person Managing the Product
(Website Manager, Adoration Coordinator, Reservation Admin, etc) Name of Person Managing the Product
(Website Manager, Adoration Coordinator, Reservation Admin, etc) Title First Last Suffix
Name of Person Managing the Product
(Website Manager, Adoration Coordinator, Reservation Admin, etc) Name of Person Managing the Product
(Website Manager, Adoration Coordinator, Reservation Admin, etc) First Last
Email of Person Managing the Product
Phone of Person Managing the Product
(for church members to use)
Mobile Phone for person managing product
(for Parish Solutions Co. to use for a text message to let you know when the product is ready.)
Current Website Address
Which Product(s) are your ordering?
(price includes 5% EAC discount for first year)

Which Product(s) are your ordering?
(price includes 5% EAC discount for first year) AdorationPro - $57/month (for 30 hours or more of adoration per week) AdorationPro - $38/month (for fewer than 30 hours of adoration per week)
Referring Organization - (Admin Use Only)
City where organization is located
Country where organization is located
State/Province/Region where organization is located
I would like to pay

I would like to pay monthly by credit/debit card (automatic recurring charge - cancel anytime) annually by credit/debit card annually by check/cheque
Email (For invoices and receipts)
Phone for Accounts Payable (if different than above) Phone for Accounts Payable (if different than above) - ### - ### ####
Name on Card Name on Card First Last
Card Number
Expiration Date
CVC/CVV Code
Zip Code with Card
Send Annual Invoice To Attention of:
Address to send Annual Invoice Address to send Annual Invoice
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country