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To enroll in Jackpot Leads and order our Online Surveyed Leads, please complete the form below. We accept Visa/Mastercard. If you prefer to order using Paypal, StormPay, or submit your credit card order by fax, simply email us to les us know. Your privacy is respected, and your information will NEVER be sold. The information you provide may be used in the event we need to confirm your order.

REMEMBER, our Surveyed Leads are scrubbed against the National Do Not Call List and are backed by a Valid Phone Number Guarantee!

*All fields are required*

*Firstname*
*Lastname:*
*Phone Number:*
*Billing Address:*
*City:*
*State:*
*Zip Code:*
*Country:*
*Name (as appears on card):*
*Type of Credit Card*
*Credit Card Number:*
*Exp. Date (MM/YYYY)*
*3-Digit CVV Code ( Back of Card):*
*Email:*
*What are you ordering?*
	Yes, I have read and agree to the terms and conditions. (Order will not be accepted without this box checked.) Check this box if you would like to receive information on our REAL TIME Online Surveyed Leads! Valid Phone Number Guarantee: We pledge to replace any lead that we have issued you that has an invalid phone number. To qualify for this guarantee, you MUST return the full lead to us within 72 hours from the time we deliver you the set of leads. Please include a brief note as to why the lead phone number was invalid (disconnected number, person on file does not live there, fax number, it was their child who submitted the form). Only those reasons listed here will be accepted as an invalid phone number. We will call the lead to verify that the number is invalid. We cannot be held responsible for a correct yet unresponsive lead. Results are based on your phone presentation, product and service you offer, and the personal choice made by the individual who has requested to receive information. If you wish to cancel your monthly autodelivery, you must give us written notice at least 4 business days from your next billing schedule to avoid being charged for the upcoming billing cycle.

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