PRE QUALIFIED WEDDINGS  LIST
ORDER  FORM

How to Use This Form:
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 . Type in the form, on screen response,  (fill out the blanks) and enter all applicable information
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 Press TAB to move from one field to another
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 If you make a mistake, erase/delete or Backspace and retype correct information
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 Please click "Back" to return to this Order Form.
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 Print Form and mail it with your payment to: Doctors Marketing Service address (shown below).
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 Please enclose the following items:
u Completed Order Form  +  Payment (check only. No credit cards).
u Orders from outside the USA, contact DMS.

Order:
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Special Offer: $2 Per lead 
Regular fee: $7/Lead
Minimum Order: $200 (100 Leads)
Your Preferred Order: 
Leads X $2/Lead = $ 
Use this section to place larger orders to lock the low fees for this Special offer.
I wish to take the 10% discount off the Special Offer. I was referred  by 
Leads X $2/Lead = $   X 10% = $ 
Minimum Order: 100 Leads
Deadline - Special Offer: March 31, 2005 (Payment received at DMS)
Total Order:
To avoid any delays in processing your order, kindly double check all selected categories and enter appropriate rates.
 
Total Amount Paid: $            Check # 
Mailing Date:

COMMENTS:

ORDER INFORMATION: (Please complete only applicable fields)
 
Name 
Title
Department 
Institution
Address 
City  State/Zip Code: 
Country
Area Code Telephone number:  FAX number: 
E.Mail Address
URL (web site address)

>>>  Please Print Completed Form And Mail It With Your Payment To:

Doctors' Marketing Service
P.O. Box 748
Lake Forest, California 92609-0748, USA
 

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