Application for AdPlacement & Insertion Order

Wewould like to advertise on one of your websites, and are submitting ourcompleted

applicationwith signature of our company’s officers along with the correct payment foryour

reviewand acceptance.   

The website that we would like toadvertise at is located at: (fill in the internetaddress or

domain name below)  

www.__________________________
 

We have completed all of the following informationfound on the application and insured that we have checked the following itemsbefore returning application and initial payment for your service:

           * selected the website or websites that you want to advertise on

*selected “Advertising Option(s) #1, #2, or #3”

* returned the ad in the wording and

* Ad may be in a foreign language but must be typed using Englishtype/characters

*signed and dated the application - application must be signed by officer of thecompany

*initialed your Acceptance of our Terms & Conditions

* enclosed the correct payment which includes 2 monthly payments consisting ofthe first
  month and last month.

Weselect the following advertising option(s):   

_______  Advertising Option # 1:  Frontpage/Homepage

We select the Top Banner Ad at$__________ / month

We select the Bottom Banner Ad at$__________ / month

NOTE:  Maximum Banner Ad Size is 728 x 90 pixels

Unlessotherwise requested, we will include a link to your website in your Top/BottomBanner Ad.

Pleaseemail us your banner ad that conforms with the above size requirements.Alternatively, we

candesign your banner for an additional fee of $995.00 wherein we will offer threecustomized

bannersfor your selection.  Additionaldesigns are $250.00/each with a limit of 6 banners that we will

proposefor a total of 9.

_______  Advertising Option # 2:  OnePage Ad Inside

NOTE:  Maximum Number of Words is 250 – Additional words available at $_______/ word.
              The average wordcontains an average of no more than 8 letters.

Our250 page ad reads as follows (Attachyour ad to the application )

_______  Advertising Option # 3:  E-mailAddress (where available)

We would like the emailaddress of:    _________________@______________

At the price of $199.95 /month

Applicant’scontact information:

Yourname:               ______________________________________

Title:                          ______________________________________

Companyname:       ______________________________________

Companyaddress:    ______________________________________

City:                          _______________   State _______________   

Zipor country code  _______________

Country                     _______________

Telephone                 _______________  (includecountry code if outside of the U.S.A.)

Fax#                        _______________

Website                     ______________________________________

Emailaddress           ______________________________________

List your primary bankingreference:

Bankname               ______________________________________

Bank’saddress         ______________________________________

 Bank’s telephone number    _______________  (includecountry code if outside of the U.S.A.)

Bankofficer’s name  ______________________________________

Websiteaddress of bank:      ______________________________

Last4 numbers of your company’s primary account number: _______________

Tohelp us better understand your company, please list all of your company’sprimary Products and Services:

                                1.  ____________________                               6.  ____________________                               

                                  2.  ____________________                               7.  ____________________

                                 3.  ____________________                               8.  ____________________

                                 4.  ____________________                               9.  ____________________

                                 5.  ____________________                               10. ____________________

How can we improve our website?  (pleaseattach your recommendations)

Terms & Conditions:

1.  All prospective advertisers must completeapplication and receive owner’s approval before acceptanceof customer's advertising insertion order.

2.  Domainname owner reserves the right toaccept or reject any application.

3.  All prospective advertisers must agree to minimumof one year advertising term.

4.  First and last month's fee for advertising arerequired at time of application. Applications without payment will be rejected.

5.  Payments must be received in our office no laterthan the 5th of every month. Advertisers that have not made payments by the 5thof the month will have their ads removed on the 6th.  

6.  All prospective advertisers applications must beapproved before new ad insertion.   

7.  Applications that are not approved by Company maybe accepted on a conditional basis for an additional pre-payment (not adeposit).   

8.  Additional deposit(s), if required, will bereturned to customer within 3 business days after 12 month term is completed,and customer is not in arrears.  Any arrearages will be deducted fromdeposit before returning.  

9.  Maximum ad size for Top and Bottom Banner ads is: 728 x 90 pixels.  

10.Maximum number of words in Option #2 (one page adinside website) is 250. 

Additional words available at $________ / word.  

11.Norefunds - no exceptions.

______________________________________
Company Officer’s Signature

______________________________________
Company Officer’s Title

______________________________________
Date

Yoursignature here indicating that you certify all of the information in theApplication above is true and correct and that you have read, understood andaccept all (11) of the Terms and Conditions above.