Advertiser's "On-Line Account" Registration

Submitter's Name:
Submitter's Email:
Advertiser's Company Name:
Company Address:
Company Phone with Area Code:
For your Advertiser's On-Line Account:
Select Password (4-8 alpha or numeric/case sensitive):
Re-Enter Password for Verification:
Ad Placement Pricing:
  "Advertiser's Online Account" Setup Price: $25/year
(With a single "Advertiser's Online Account", you may post an unlimited number of Display Ads!)

Ad Processing Price: $100 per Ad, plus either $10/month (Plan A) or $15/month (Plan B)

(Plan A is for a local (one) state listing and Plan B is for a multi-state listing. You specify which states in which your Ad will appear! The Display Ad will run continuously until terminated by you, the Advertiser.)
Process your own Advertiser On-Line Account:
Type of Account: Advertiser's ON-LINE Account
Credit Card Charges: $25 for "On-Line Account" Set-Up Fee
Name on Credit Card:
Credit Card Number:
Expiration Date:  / 
Type of Card:
Yearly Renewal Period:

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