Advertisement Form  -  OC Women Groups Directory

 How to use this Form:
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n Use one Form per Order.
n Type in the Form, on screen response, (complete applicable blanks). 
n
 Press "TAB" to move between blank spaces. 
n
 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
Title:
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: 
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Number  Street  Suite #
City
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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