Infopage Services Promotion Non-Secure Order Form Please contact us immediately if you have problems using this form.
First Name:
Last Name:
Email Address:
Business Name:
URL:
Keywords:
Address Information:
Line 1:Line 2:
City:State:
Zip/Postal Code:Country:
Phone: Fax:
Account ?
$30 option $55 option
$50 engine presence service $30 with an option above
Payment Method:
Credit Card
Check online/fax
Snail Mail (credit card/check or money order US funds)
Expiration:
Card Type: Visa MasterCard American Express Discover
Check Information:
Take care in filling out all the information correctly.
Name (as appears on check): CHECK PAYMENT INFO: (As it appears on your check!) Note: If you're confused as to what is what on your check, asks your banker will be happy to help. Address: Line 2:
Check #: NOTE: Get out your check book and use the next available number Be sure to make an entry for this check in your Check Register Bank Name: Bank Address: Bank City: Bank State: Bank Zip Code: Phone Number: Bank Routing# (ACH#): NOTE: The routing # digit# at the bottom of your check on the MICR Line. Most likely the left-most series of numbers Branch Fraction: TOP#: BOTTOM#: [ NOTE: This is the Fraction at top-right of check near the check# ] Your Checking Account#: If your account has pre-digits enter your account number as NNN|XXXXXX where NNN are the predigits ( the number 725 before the customer number in the above example) and XXXXXX is your account number. Always separate the two with | Bank Draft Total: Check this box to Authorize payment for the total amount listed above by bank draft. Check to authorize check to be made out to "Infopage Services"
These 2 boxes must be checked in order to process your account.