Referral Site Order Form

COMPANY:
STREET:
CITY:
STATE:
ZIP:
CONTACT:
E-MAIL:

The charge for a Referral Site is $149.95

For payment by Check of Money Order, make it payable to "Surfpage" for $149.95 and mail to:

SurfPage
PO BOX 17053
Long Beach, CA. 90807

For payment by credit card (VISA or Master Charge) call 562-989-6656 or complete the following:

CARD TYPE:	MasterCard Visa
CARD NUMBER:
EXPRIATION DATE:
NAME (Cardholder):

Press on Submit Form to enter your order and to indicate that you have read and accepted the Terms and Conditions of Sale.

The above charges are a quarterly fee and due before the service is activated and can be accessed. Subsequent fees are payable annually on the same day that the site was activated.