| PERSONAL CONTACT INFORMATION |
| First Name: Last Name: Company Name: |
| Mailing Street Address: Suite #: P.O. Box: |
| City: State:
Zip Code: |
| Daytime Phone : - ext. Fax#: - |
| E-Mail: Confirm E-Mail: |
| Website URL (if any):
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| WEBSITE INFORMATION |
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| PAYMENT INFORMATION |
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Credit card type:   
| Your order is
secured through the PayPal processing system. |
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Card Holder Name (on card) |
| Card Number: Expiration Date : MM/DD/YYYY |
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| Billing Street Address: Suite #: P.O. Box: |
| City: State:
Zip Code: |
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| SALES PROMOTIONS/COUPONS |
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| Coupon Code: Sales Person Code: |
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| I hereby authorize Marketing Services On The Web, LLC, i.e. The Toma Group, to charge the above credit card for the setup fee of $ for a Co-sponsor. |
| In addition, I hereby authorize Marketing Services On The Web, LLC, i.e. The Toma Group, to automatically bill the recurring charges of per month as a Sponsor, or per quarter as a Co-sponsor, to my credit card for each billing period. The first installment shall be prorated from the date of first posting the web site to the internet through the end of the first billing period. Thereafter, each billing shall be charged on the first of the month, in advance, for the period of service, which is monthly for Sponsors, and quarterly for Co-sponsors. Sponsor/Co-Sponsor will receive an e-mail confirmation upon site activation. |
| I hereby agree to the Terms and Conditions of Use, Privacy Policy, Sponsor Terms and Conditions, and the Terms of this Order Form. |
| I understand that this order is subject to prior order of the same city and the same Sponsorship or Co-sponsorship. Marketing Services On The Web, LLC will notify me of prior sale of this city and will not make any charges to this credit card unless said Sponsorship/Co-sponsorship is available. |
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| Special Instructions, Comments, etc |
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