Infopage Services Promotion Non-Secure Order Form
Please contact us immediately if you have problems using this form.

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First Name:

Last Name:

Email Address:

Business Name:



Address Information:

Line 1:Line 2:


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)

NOTE:  All check/money order payments require a first and last
month's deposit.  Please submit three month's charges, plus setup
fees.  Don't forget to add amounts for options.   Contact us if further
arrangements are necessary.
Credit card Info:
Name on Card:
Card Number:


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:


Zip/Postal Code:Country:

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.  

Infopage Services
5261 Highland #395
Baton Rouge, La. 70808