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 :________________________________________________



Country:_________________________Zip Code:______________________

Email: ____________________________________________


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.



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