Circular City General Order Form : Wilco Marketing

Quick Action General Order Form
Use For General order to: Circular City at: http://www.homeincome.com/circularcity.

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 . Please note that in order to send you your order, your e-mail address must be valid.

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 for hosting orders) Max 8 characters. No spaces, symbols, punct. marks
Website Name ( Back-Up Choice ) : (use this when applicable for hosting orders) 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: Add 10% of the total order for shipping within the continental US & Canada. For orders under $25.00, remit $5.00 to help cover freight. Overseas Add 25% For Fast Air Mail Shipment U.S. Funds Only. Prompt Service!

PAYMENT INFORMATION:s

Payment Method: Credit Card Check MoneyOrder

Important: If you wish to send information via post office, Make payments payable to:
Send Payment (Cash, Check or Money Order)
To Fax Check, secure check to Order Form and fax to: (510) 741-9700
WILCO MARKETING
P.O. Box 196
Pinole, CA 94564
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:

Credit Card Authorization
(type 'I AGREE'):

Additional Comments:

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

_{EACH
WEBSITE IS INDEPENDENTLY OWNED}
_{COPYRIGHT 1998 TargetMan
Agency}
Graphics �1998 by TargetMan�_{THANK YOU FOR YOUR ORDER.}

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