www.nearkshopper.com
                              The most Convenient & Inexpensive
                                 
way to advertise on the Internet
                                     Let Your Business be Seen all over the World !
Business Name_________________________
Street_________________________________
City__________________________________
Zip Code______________________________
Email Address__________________________
Web Site Address_______________________
Phone_________________________________
Price for 1 year_________________________
Trade web site link Yes_____     No_____
Credit Card # for web site
(this is for yahoo)______________________
Name on card__________________________
Expiration Date_________________________
Credit Card Name______________________
 
   Write in Other Information
Signature:_____________________________
Sales Rep._____________________________
Client Signiture_________________________
Date__________________________________
Price to:
Build Web Site_________________________
# Pages________________________________
Domain Name__________________________
Pictures $25.00_________________________
Logo $25.00___________________________
Pass Word_____________________________
Mothers Maiden Name__________________
Clients Age____________________________
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