Friday, Jul 30, 2010

TopChiropractors.com » Professional Listing & Banner Ad<br />Secure Order Form

Professional Listing & Banner Ad
Secure Order Form

Please provide the following information so we can get your listing or ad posted right away.

Contact Information

Your Name:
Title:
[if applicable]
Company:
[if applicable]
Street Address:
[as it appears on your credit card statement]
Address Line 2:
[if applicable]
City:
State/Province:      Zip Code: 
Country:
Phone:
[ie. 212-555-1234]
FAX:
[if applicable, ie. 212-555-1234]
Web Address:
[ie. http://www.yoursite.com]
E-mail:
[ie. yourname@yourhost.com]

Select from among the following options:

Professional Listings

Featured Listing - 1 Year - $29.99  Hurry! Sale Ends Today.
Basic Listing - 1 Year - $22.00
Renewal Listing - 1 Year - $19.99  Offer Expires in 24 hours!
National Listing - 1 Year - $124.95  Special Sale Price!

Banner Advertising & Design

120x60 Banner Ad on Home Page - 1 Month - $50.00
468x60 Banner Ad on Any Other Page - 1 Month - $100.00
120x60 Banner Ad on Any Other Page - 1 Month - $35.00
Banner Ad Design - Any Size - $60.00

Banner/Listing Information

Under which regional location should your listing and/or banner ad appear?

Under which services should your listing and/or banner ad appear?
Allergies Asthma
Backache Carpal Tunnel
Elbow Pain Fibromyalgia
General Wellness Headaches
Hip Pain Joint Pain/Problems
Knee Pain Lower Back Pain
Muscle Stiffness Neck Pain
Sciatica Shoulder Pain
Sports Injuries Stress
TMJ Whiplash
Short 8-12 word description of your services
to be included in your featured listing:

Billing Information

Payment Method:
Cardholder Name:
[as it appears on your credit card statement]
Credit Card #:
[no dashes or spaces]
Exp. Date: /


TopChiropractors.com collects only the information necessary to carry out the transaction
related to your purchase. The information we collect is NEVER shared with anyone else.

Please print a copy for your records before submitting.

Charges on your credit card will appear as “Precision Marketing Solutions, Inc.”

   
Your order will be reviewed and processed within 48 hours.