What kind of Ad would you like to place?

 

Free Month Listing

Your Company/Your Name

Your Address

Your Phone

http://

 

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

 

General Listing · $12.95 per month

Your Company/Your Name

Your Address

Your Phone

A Listing of your Comapny 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? Select Ophthalmology Dermatology Plastic Surgery Podiatry Oncolgy Cardiology Otolaryngology Otorhinolaryngology Other (Hold the shift key to select multiple categories)

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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