What kind of Ad would you like to place?

 

General Listing · $12.95 per month

Your Company/Your Name

Your Address

Your Phone

 

A Listing of your Company Name, Address, and One Phone Number.

 

 Silver Package · $29.95 per month

 

Same as above plus a link to your web page or email & a 25 word description. Also Bold-Highlighted Listing http://

 

Gold Package· $49.95 per month

Same as above plus guarantee one of the top five positions in that city.

http://

 

 

Platinum Package · $99.95 per month

All the above, plus we guarantee # 1 position in your city.

http://

 

 

 

Enter your listing (As You Want It To Appear):

Company Name:
Address:
City/State/Zip:
Country:
Phone Number:
Toll Free:
E-Mail*:
Contact Name*:
* will not appear on your advertisment

 

****What category of Laser Treatment do you perform? (very important)

How did you find us? Select One Post Card Phone Surfing Referred by Other Renewal Search Engine E-mail Notification Advertisement Trade Show Association Upgrade Listing Other Specify:

Comments:

Customer Status: New | Existing | Renewal

Renewal Info ONLY: Customer # | Invoice#

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Pay By Check Mail a Check payable to: "Laser Treatments Dot Com" 10619 Melvin Ave. Northridge,CA 91326

By Check: Check - Ck #   | Money Order

Total Amount: |  Date Mailed:

Your Listing will be Posted ONLY when we receive your check.

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	Pay By Credit Card
Card Type: Visa | Master Card American Express | Discover | Diners Club
Card Number: - - -		Exp:
Billing Name:
Address:
Address:
Total Amount:

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