General Order Form

Secure Online Order Form
Please fill out the form below. When you are done, check for accuracy and
be sure to click on the "Submit" button on the bottom of the form.
If your browser cannot handle forms or if you have problems with this form, e-mail us your order at order department or software department. Please note that in order to send you your order, your e-mail address must be valid.

Only fill in items and fields that apply to your specific order. Do Not worry! Once we receive your order a real human will go over it and email you with a reply and ask you for any information you might have missed.

What is this order for?: (Enter a brief description of what this order is for)
What WebSite URL is the item on?: (Enter http:// URL of where you saw the product(s))
Listing Entry : (use this when applicable for listings and ads)
Website Name ( Primary Choice ) : (use this when applicable) Max 8 characters. No spaces, symbols, punct. marks
Website Name ( Back-Up Choice ) : (use this when applicable) In case your Primary Choice is already taken

Mailing Information:

Your Full Name:

Company Name:

E-mail Address (required):

Daytime Phone Number:

Address:

City:

State:

Zip:

Country:

Other General Order Information:
Fill in item(s) where applicable AND/OR You may also find it more appropriate to use the
"Additional Comments" box at bottom of this form for describing your order.

Item Number Item Description Quantity Price

Sub-total

Misc. Amounts

Shipping Charges*

Grand Total

*Shipping Charges: For products only (not services) Add 15% of the total order for shipping within the continental US. For orders under $25.00, remit $5.00 to help cover freight.
PAYMENT INFORMATION:s
Payment Method: Credit Card Check MoneyOrder
Important: If you wish to send information via post office, Make payments payable to:
TargetMan Agency
P.O. Box 399, Lubec, ME. 04652 USA
and print out and mail this form with proper payment.
Fill out the credit card info below:

Credit Card Type:

Name on card:

Card Number:

Card Exp. Date: Month:--- Year:

Credit Card Authorization
(type 'I AGREE and Amount'):

Additional Comments:
Where Did You Hear About Us?:
Search Engines (Enter Name)
Direct Email
Our Website
Print Advertising
Other

Click your back button if you do not want to place an order yet.

_{EACH
WEBSITE IS INDEPENDENTLY OWNED}
_{COPYRIGHT

TargetMan Agency and HomeIncome Publishing Group
THANK
YOU FOR YOUR ORDER.}

Your Full Name:
Company Name:
E-mail Address (required):
Daytime Phone Number:
Address:
City:
State:
Zip:
Country:

Credit Card Type:
Name on card:
Card Number:
Card Exp. Date:	Month:--- Year:
Credit Card Authorization (type 'I AGREE and Amount'):