Club Information

Name Of Club (Required)

Club Full Address (Required)

Club Phone Number (Required)

Logo Of Club

Contact Person For Monthly Updates

Name (Required):

Phone Number (Required):

Email (Required):

Social Media Address

Facebook:

Twitter:

Instagram:

Details About Club

Hours Of Operation (Required):

Sunday:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:

Details About Club (Nude, Topless, GoGo, BYOB, Cover Charges, Dance Charges, Age To Enter, etc.) (Required)

Once a month deals you want to offer customers (FREE Pass, 241 drinks, 241 dance, 1/2 off bottle service, FREE drink etc.) (Required)

Food Menu:

Drink Menu:

Promotions/Events/Specials:

Pictures Of Club:

Payment Info (Required):

Name On Card:

Card Number:

Exp:

CVC:

Billing Address:

 Add bi weekly posts to our social media pages (over 80,000 followers )For An Extra $19.99 Per Month

I hereby authorize Xtreme Publishing LLC to initiate a charge or debit entry on my credit card, debit card or deposit account (as applicable) for the total amount due each month after 30 days from today's date for the services provided to me by Xtreme Publishing LLC. I acknowledge that the origination of a charge or debit entry to my account must comply with the provisions of U.S. law. This authorization will remain in full force and effect until the date upon which Xtreme Publishing LLC has received notification from me of my election to terminate this recurring payment program in such time and in such manner as to afford Xtreme Publishing LLC and my financial institution a reasonable opportunity to act on it. Such notification must be submitted in writing through mail and sent to Xtreme Publishing LLC P.O. Box 38 Kensington, CT 06037.

I agree to maintain balances sufficient to pay all requested payments, and agree that Xtreme Publishing LLC is not liable for any overdraft or insufficient fund situation or charge (including, but not limited to, finance charges, late fees or similar charges) caused by my failure to maintain funds sufficient to pay all payments issued through this recurring payment program. I further agree that Xtreme Publishing LLC may charge a reasonable service fee for any charge or debit transactions that result in a returned debit entry, including, but not limited to, returns resulting from insufficient funds in my account, closure of my account or incorrect account or routing information provided by me. I agree to promptly notify Xtreme Publishing LLC in writing of any changes to the financial institution account information and hereby grant authority for Xtreme Publishing LLC to charge or debit such changed account. I agree Xtreme Publishing LLC will not be responsible for any expense that I may incur from exceeding my credit limit or overdraft of my account as a result of a charge or debit made pursuant to this recurring payment program.

I Agree