AboutKY.com - Ads Order Form

AboutKY.com - Ads Order Form

9/3/2010 AboutKY.com INV: 7752

P.O. Box 808

Tel: 859.887.9432 - Fax: 859.885.2377

Days Description Cost Total

120 Day AboutKY.com And Bluegrass Living - Classifieds Display Ad $ 16.99 $ 16.99

Please complete the following, if you do not wish to use the PayPal method above.

BILL TO: ( All fields below are Required - Except Fax! )

First Name	Last Name
Company Name	Customer Type	Individual Business
Address
City	State		Zip
Country
Day Phone	Fax
E-mail

PAYMENT METHOD:

IMPORTANT: (Name & Address entered above must match the Credit Card Account below!)

Credit Card
If Credit Card is selected please also complete the Credit Card Information section to the right.
(Do not include spaces)

Credit Card Information
Card Name

Card Number:

Date Format: i.e. 09/01
Expire Date:
/

CVV No:
	( The last three or four digits on the back of your card! )

Electronic Check If Electronic Check is selected please also complete the Check Information section to the right. (Do not include spaces)	E Check Information Drivers license State: State:	(All Fields Are Required) Drivers License Number: Drivers License DOB:
The Account Type: Checking Savings	Bank Name: The Account 9-digit routing numeric value. ABA Number:	Account Name: The Account number a numeric value of variable length. Account Number:

Pay by Check
If Pay by Check is selected please see the Note to the right

Note: If you do not wish to place your credit card information on this form, you can select the Pay by Check option, and when you receive your conformation Email Receipt,
you can either;
1. Fax your signed order to our office. (Fastest and most Secure)
2. Secure Email it back to us with your signed information.
3. Print out the Email Receipt and along with your payment, send it US Mail to us.

Fax Email Mail In

Please enter any comments you may have.