ORDER FORM FOR
EastBiz.com, Inc., info@eastbiz.com
Agent name:
__________________________Broker name: ____________________________
(AGENT)
Company
name: _________________________________________________________
This is order form for (check one)
_____ LIGHT
SEARCH IDX: $49 one time set up fee. $9.95 per month.
_____FULL
VERSION IDX: $99 set up and $250 per month
Header & bottom set up:
Take design
from this WWW__________________________________________________________
This
contract can be cancelled anytime without reason by any party with written
notice. Prepaid amounts will be refunded based on the regular monthly rate.
Refunds are for the pre-paid and unused months only. Set up fees are not refundable.
I authorize Eastbiz.com, Inc. to debit my credit card. Bill me __ monthly __ year in advance
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Check one: |
__ VISA __MasterCard __Discover __AMEX |
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Credit Card Number: |
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Name on the card: |
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Expiration date |
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Billing address (street, apt. #) |
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City |
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ZIP |
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State |
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Phone,
fax, email: |
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Signature Of Card
Holder______________________________ (Signature is
required)
Provider
name: ___________________________________
Please
fax back to (702) 507-1467, phone: 702-296-0212