U-Web Internet Services Online Order Form
SEVICE REQUESTING : ADD
Name:________________________________________
E-Mail: _______________________________________
Company: ____________________________________
Street Address: _______________________________
City, State, Zip: ________________________________
Phone: _______________________________________
Special Instructions: _______________________________________________________________
____________________________________________________________________________________
Payment Type
_____Credit Card_____Check, _____ Monery Order , _____ Chasier check
Credit Card/Check/Money Order/Cashier Check# ______________
Credit Card EXP. DATE ______________________
Name on Credit Card ________________________________
Service Requesting:____BILLBOARD,____News Ticker,____Headline
Payment Terms : Monthly $7.50
Pre-Payment: _____1 month $7.50,_____2 months $15.00,_____ 3 months $22.50, _____4 months $30.00,_____5 months $37.50,_____6 months $45.00,_____7 months $52.50,_____8 months $60.00,_____
9 months = $67.50,_____10 months = $75.00,_____11 months = $82.50,_____12 months = $90.00
AMOUNT $__________
Accounts Include:
Prices include page design & maintenance,Your address added to 200 search engines: One Billboard or Headlines or Ticker options. Additional options $10.00
Signature : ___________________________________