| PERSONAL CONTACT
INFORMATION |
| First Name:
Last Name:
Company Name:
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| Mailing Street
Address:
Suite #:
P.O. Box:
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| City:
State:
Zip Code:
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| Daytime Phone :
-
ext.
Fax#:
-
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| E-Mail:
Confirm E-Mail:
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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)
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| Card Number:
Expiration Date
:
MM/DD/YYYY |
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| Billing Street Address:
Suite #:
P.O. Box:
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| City:
State:
Zip Code:
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| SALES PROMOTIONS/COUPONS |
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| Coupon Code:
Sales Person Code:
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SETUP FEE :
One time setup fee - $
I wish to pay the setup fee upfront. I understand that this will result in a $ savings. 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 $.
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RECURRING CHARGES :
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. |
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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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