"VISIONS" INVESTMENT CLUB

Your First Name: _____________________________________________

Your Last Name: _____________________________________________

Your Company Name: _________________________________________

Your Title: ________________

Address etc.

Street Number: ________________

Street Name: __________________________________________

City: ____________________________________

State & Zip: ____________________________(_____________)

Office Phone: (__________)___________________

Fax: (___________)__________________________

Home Phone: (_________)_____________________

Pager: (__________)______________________

E-mail: ___________________________@________________________________

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ANNUAL FEE: $500

6 MONTHS $250 (Payable in Advance)

CHECK-MONEY ORDER-WESTERN UNION

TO: STEPHEN MOUTON, Inc.

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Fax To: (337) 269-1817 OR MAIL TO:

Stephen Mouton Inc.

201 Alfred Street

Lafyayette, La. 70501