Please print the following form and return it via fax if using paypal or via postal mail if using payment by company check, or money order. Payable to: Micro Online Services, Inc.
Fax 1-213-341-0808
Micro Online Services, Inc.
3525 Del Mar Heights Road,
#408
San Diego, CA 92130 USA
1-800-806-3210 x707 ( toll free USA)
1-213-341-0808 x707 (International)
Or fax 1-213-341-0808
Adult Advertising Purchase Order
Company Name :__________________________________________________
Contact Person :________________________________________________
Address:________________________________________________________
City:_________________________State/Prov:_______________________
Country:_________________________Zip Code:______________________
Email: ____________________________________________
Phone:_______________________Fax:_______________________________
Destination URL to send traffic ___________________________________
Url of graphic to be used ________________________________________
All prices are in US Dollars. Please check which program you
wish to order.
___ Adult Clickthru Button Program 3,000 clickthrus $450 ________
__ Adult Clickthru Button Program 5,000 clickthrus $600 ________
__ Adult Impression Banner Program 40,000
views $240 ________
Total Enclosed $________
Payment Method
___ Money Order (US$ payable on US Bank) ___ Personal Check (US$ drawn on US Bank) ___ Cash Currency US$ send via REGISTERED mail ONLY. ___ Visa ___ MasterCard
All payments should be in US $dollars. Checks or drafts should be issued by U.S. Banks made payable to Micro Online Services, Inc.. Company checks or bank drafts are preferred.
If paying via credit card, please complete the following and provide signature of card holder.
Credit Card Information
Credit Card Number:___________________________ Issue:_____ Expiry:_____
Your Name as printed on Card(PleasePrint):_____________________________
If billing address is different from address shown above, please write billing address here.
Address:________________________________________________________
City:_________________________State/Prov:_______________________
Country:_________________________Zip Code:______________________
I hereby authorise Micro Online Services, Inc. to charge my Credit
Card, indicated above by the amount of $ ________US dollars.
Signature_________________________ Date _________________
Micro Online Services, Inc. copyright@2010