Applicant's Last Name:

 Applicant's First Name:

 Mailing Address:

 City:     State:     Zip:

 Phone Number:     Date of Birth:

 Number of persons in household: 1 2 3 4 5 6 7

 By submitting this application agreement and later using (or authorizing another person to use)

 my Paul's Club Card, I understand that purchases made using the Paul's Club Card will be

 automatically recorded, which allows Paul's to provide me the special offers and information

 about items that may be of interest to me.

 In consideration of my privacy, Paul's Markets will not release the above information

 for use by any outside company.

I AGREE

Check only if you DO NOT wish to receive coupons, offers or other information by mail.