U-Web Internet Services Online Order Form

SEVICE REQUESTING : ADD
Print and send form plus Check/Money Order/Cashier Check payable to:
UWIS
1200 McKinney, Suite 411-242
Houston, TX 77010


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 : ___________________________________