Business Advertising Sign-up Form



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Business Advertising Sign-up Form

Please fill out the following form to sign-up for Business advertising on the CanadaAtNight.com web site. Provide as much detail as possible, as your potential clients are looking to find out as much detail about you. The more information and pictures that you provide, the more calls and inquiries you will get.

Personal Information

Name:
Email:
Web Site:
Address
Phone:
Fax:
City:

This information will be shown in the advertising. Please fill in all the required fields.

Business Profile

Description:
Pictures:
Accessibility	Entry: Washrooms: Service for Persons with Disabilities:
Hours of Opreations:	Mon-Wed: Open: Close: Thursday: Open: Close: Friday: Open: Close: Saturday: Open: Close: Sunday: Open: Close:

Please take your time in this area. The more information you provide here, the more successful your ad will be.

Categories

Adult DVDs/Videos		Adult Entertainment
Adult Stores		Adult Toys
Bars and Clubs		Dating agencies
Business Services		Massage
Clothing and Accessories		Restaurants
Restaurants		Strip Clubs

Misc:

Please select the categories that apply.

Sales Associate ID:

Advertising Packages

Choose an advertising package (prices include GST):

The only difference with standard and premium is that your ad will be place above the standard A-Z listings.

Automatically renew my account on a monthly basis

6 Month Standard Directory Listing ($265.00) - 1 month free

12 Month Standard Directory Listing ($530.00) - 2 months free

6 Month Premium Directory Listing ($397.50) - 1 month free

12 Month Premium Directory Listing ($795.00) - 2 months free

Payment Information * All of the following is required to process your order

How would you like to pay for your ad? Note that your ad will not be posted until payment is received.

Visa Mastercard Paypal Cheque/Money Order Western Union

if you would rather call us with your payment information, dial 1-866-729-9653

If you are paying by credit card, fill out the following information:

Credit Card #
Name on Credit Card:
Billing Address
Expiry Date:
CVV2 Code: (The last 3 or four numbers on the back of your card)

Form Security

* You must enter the correct code for the form to be submitted.

Code:


	<a href='http://unitedstatesatnight.com/adserver/www/delivery/ck.php?n=a2e73b27&cb=INSERT_RANDOM_NUMBER_HERE' target='_blank'><img src='http://unitedstatesatnight.com/adserver/www/delivery/avw.php?zoneid=13&cb=INSERT_RANDOM_NUMBER_HERE&n=a2e73b27' border='0' alt='' /></a>

	<a href='http://unitedstatesatnight.com/adserver/www/delivery/ck.php?n=a2e73b27&cb=INSERT_RANDOM_NUMBER_HERE' target='_blank'><img src='http://unitedstatesatnight.com/adserver/www/delivery/avw.php?zoneid=13&cb=INSERT_RANDOM_NUMBER_HERE&n=a2e73b27' border='0' alt='' /></a>

	<a href='http://unitedstatesatnight.com/adserver/www/delivery/ck.php?n=a2e73b27&cb=INSERT_RANDOM_NUMBER_HERE' target='_blank'><img src='http://unitedstatesatnight.com/adserver/www/delivery/avw.php?zoneid=13&cb=INSERT_RANDOM_NUMBER_HERE&n=a2e73b27' border='0' alt='' /></a>

	<a href='http://unitedstatesatnight.com/adserver/www/delivery/ck.php?n=a2e73b27&cb=INSERT_RANDOM_NUMBER_HERE' target='_blank'><img src='http://unitedstatesatnight.com/adserver/www/delivery/avw.php?zoneid=13&cb=INSERT_RANDOM_NUMBER_HERE&n=a2e73b27' border='0' alt='' /></a>

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