Company Name: 

Your Name:     

Title:              
(i.e. Webmaster, Owner, Etc.)

Your Email:     

Your Website:     
(i.e. www.yourURL.com)

Daytime Phone: 

Your Billing Address: 
Street        
State:       Select State... AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY D.C. PR US VI          Zip:

Please Choose the Family4Life AdPlan: 
(If you prefer to choose more than one, please choose your first option here, and use the "Special Instructions" box below to list your additional choices).
choose... #1 Homepage Banner Ad Top (large) $250 #1 Homepage Banner Ad Top (small) $75 #2 Homepage Banner Ad Bottom (large) $150 #2 Homepage Banner Ad Bottom (small) $50 #3 Homepage Text Link Top $25 #4 Homepage Text Link Bottom $15 #5 Page Specific Banner Ad Top (large) $100 #5 Page Specific Banner Ad Top (small) $35 #6 Page Specific Banner Ad Bottom (large) $50 #6 Page Specific Banner Ad Bottom (small) $25 #7 Page Specific Text Link Top $15 #8 Page Specific Text Link Bottom $10

Please choose the quantity (# of links/# of banners):

If You Selected a Page Specific AdPlan, Please Choose from the Following Page(s) Where You Would Like Your Advertisement to Appear:  choose... Original LaborGear Bag Junior LaborGear Bag Nurse Nana Daddy2Be Mommy2Be Daddy4Life Mommy4Life Family Business Mommy's World Daddy's Corner Family Humor Family Topics Family4Life Family Tree
(NOTE:  If you prefer to choose more than one AdPlan, please use the "Special Instruction" box below to offer more detail as to which banner or text link to place on which page, respectively). 

*Payment Information
Select......................................................... Visa Mastercard American Express Discover

*Credit Card Number                       *Expiration Date (Month/Year)
            Month... JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC         Year... 2002 2003 2004 2005 2006 2007 2008 2009 2010

(If you prefer to pay with company check, please complete this online agreement.  Credit card information is required to support check payments.  Mail your check within 15 business days to):
  Family4Life L.L.C.
 16989 Descartes Drive
 Loxley, AL  36551

*Is Credit Card Billing Address the Same as the Billing Address Entered Above?   YES    NO
(If "NO," Please enter credit card billing address above as "Your Billing Address").

*"I Would Like to Save 10%, Sign Me Up for 12 Months?   YES    NO
(If "NO," Please enter credit card billing address above as "Your Billing Address").

URL Address You Will Use to Link to Your Advertisement:   
(i.e. "www.yourURL.com/special_page.htm")

If Choosing a Banner AdPlan, Please Provide the URL Address for the Banner Image You Would for Us to Use:         (i.e. "www.yourURL.com/service/image.gif")

If Choosing a Text AdPlan, Please Provide the Text EXACTLY as You Want it to Appear on Our Webpage(s):    (i.e. "Eat at Joe's!", limit of 20 characters)

Briefly Describe Your Website, Line of Business, Trade, Service, Products, Website Content, Etc.

Briefly Describe Your Web Audience (who looks at your site, age, income, group, etc.?):

How Many Page Views/Month Do You Get on Your Website? 

How Many Hits/Month Do You Get on Your Website: 

Any Special Instructions?
 

Thank You.  Please press submit to send your form to us.  

Please allow up to 10 business days to review your request.  Family4Life reserves the right to refuse any application and/or cancel any AdPlan at their discretion, and with notice.  Each AdPlan is auto-renewed at the end of the original time period, and may be cancelled in writing (email is fine) at least 10 business days before the auto-renewal date.  For questions or to make AdPlan changes, please contact us: advertise@family4life.com. If you agree to these statements, please click the submit button to complete your agreement.