Web Advertising Order Form

Name*
First Last
Title
Company
Email*
Enter Email Confirm Email
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Organization/Individual Name Wishing to Advertise on ASISNYC.org*
Brief Description of Advertising Organization
Desired Banner Size
- 175 pixels x 107 pixels
Desired Position for Banner
- Sponsor Banner
Banner Link*
Need help creating the ad?
- Yes
- No
If you have artwork please attach it here
Accepted file types: jpg, gif, png.
Please provide JPG, GIF or PNG files. No Flash files accepted.
Duration of Advertising
- Six months - $600
- One year - $1000
Credit Card

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MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
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