Name:
    Title:
  Company:
  Address:
City/Prov: State: 
 Zip Code:  Country:
  Phone #: FAX #:
   E-mail:

      
     Name:
    Title:
  Company:
  Address:
City/Prov: State: 
 Zip Code:
  Country:
  Phone #: FAX #:
   E-mail:

PAYMENT METHOD

Bill Us PO# (for open accounts)
Check mailed. #
New Account Credit (Complete credit application)

MasterCard. Visa. Discover. American Express.
Card Holder:
Card Number:
Expires: /(Example:05/99 mo/yr)

ORDER FORM

Please choose the PR Services you wish to order from the following:

#1 PR submitted to over 5000 newspapers, magazines, radio, and TV stations.......................................................................only $249
#2 PR submitted to targeted industry media of your choice.........................................................................only $99
#3 Web site submitted to over 600 search engines and directories..................................................................only $28.99
#4 Laser printed labels...0.10 X
#5 Targeted e mail addresses...0.10 X

INFORMATION:
Please enter the following information only if you have ordered a Press Release Submission #1 or #2:
Contact Person
Contact Phone#
Contact FAX#
Contact E-mail

Press Release Title:

Press Release (up to two pages of news or information):

Target industry media you wish to send your PR to. Choose 3 from the categories section. You only need to fill this section in if you ordered #2:

Please enter the following information only if you ordered the Website Submission #3:
Contact Name
Contact E-mail

Website Title (maximum 15 words):

Website URL:(ex: http://www.yoursite.com)

Category you want your site submitted to e.g. pet supplies, business, etc.:

Site Description (maximum 250 characters):

Key Words (maximum 1000 characters. Please separate words/phrases with a comma):

Please enter the following information only if you ordered Laser Printed labels (#4):
I want the following laser printed labels:
1,600 Daily Newspaper laser printed labels
7,500 Weekly Newspaper laser printed labels
8,700 Radio Station laser printed labels
1,600 TV Station laser printed labels
3,400 Magazine laser printed labels
Businesses with:
S.I.C. code

Yellow page heading laser printed labels

Please enter the following information only if you ordered targeted e-mail lists(#5):
Compile a targeted e-mail list for each of the following search criteria (e.g. pet suppliers, business, baseball etc.)

PLEASE ALLOW AT LEAST 30 SECONDS FOR THIS FORM TO PROCESS.