 |
|
To serve you better, we are currently revising our electronic order form.
Please print this out and fax to: 203-834-2409
Purchase Date __________________
Billing Information
Salutation ____ First Name _____________ Last Name __________________
Title __________________________
Billing Address
Company _______________________________________
Address ________________________________________
City __________________State ______Zip Code _______
Phone ________________ Fax _____________________
e-Mail _________________________________________
E.I.N. _________________________
Payment (circle one) Cash Check Purchase Order Credit Card
Check Number P.O. Number
Number
Confirmation via (circle one) Fax e-mail Snail Mail
Ad Information
Company _____________________________
Address1 _____________________________
City _____________ State ____ Zip Code _______
Phone _____________ Fax _______________
e-Mail _______________________________
E.I.N. ______________________
CityPilot Site City _____________________
CityPilot Site State _______________________
Page __________________________________
Purchasing (circle one) Page Sponsorship Banner Ad Hot Link
Banner Specs (circle one) I Need A Banner I Will Supply My Own Banner
Banner Copy _________________________________________
_____________________________________________________
Banner Copy Contact __________________________________
Hot Link First Choice ___Second Choice ____Third Choice _____
Fill out information below for Page Sponsorships, Banner Ads and/or Hot Links
Hot Link to (URL) _______________________________________________
Hot Link Name ____________________________________________
Price ___________________
Applicable Taxes ___________________
Applicable Banner Set-up Fees ___________________
Applicable Web Site Dev. Fees ___________________
Total Cost ___________________
Salesperson ______________________________________________
Distributor ID # ________________________________
Customer Acceptance by ________________________________________