Advertisement Form  -  OC Women Groups Directory

 How to use this Form:
n Use one Form per Order.
n Type in the Form, on screen response, (complete applicable blanks). 
Press "TAB" to move between blank spaces. 
DO NOT CLICK ON "ENTER" while completing the form. If you do that, you will close the form and send incomplete Form!
n DO NOT press the  "BACK" button because all information will be deleted if you leave this web page.

Contact  Name:
First Name
Middle Name
Last Name
Business Name:

.I would like to order advertisement/link at OC Women Groups Directory for the following periods :

1 year:   Banner Ad: $355    Gold Position: $195   Platinum Position: $145   Standard Ad: $115

2 years:  Banner Ad: $497   Gold Position: $273  .Platinum Position: $203   Standard Ad: $161
With 2 year ads,  you will receive an additional FREE 6 months advertisement (offer end June 30, 2007)

Total Order (please add the amounts at all checked boxes and enter here): $.
Check Number:     Date: 

Your Address And Contact Information: 
Number  Street  Suite #
State/ Zip Code
Country Code (USA, leave blank) . Area Code.
Telephone Number
FAX Number 
E-mail Address
Web Site Address (if available)

Please complete Advertisement Form, print it and mail it with your check to:

Doctors' Marketing Service
P.O. Box 748, Lake Forest, California 92609-0748

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