SECURE ON-LINE ORDER FORM

Please note: THE INFORMATION YOU PROVIDE ON THIS FORM IS FULLY SECURED. Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: order@gotomymall.com.

CLASSIFIED AD SUBMISSION
Promotional Prices	Duration	Guarantee: If not satisfied, Ad runs additional days
$20 $30 $50	3 months 6 months 12 months	30 days 60 days 90 days

MIRROR HOMEPAGE SUBMISSION
Promotional Prices	Duration	Guarantee: If not satisfied, page runs additional days
$60 $100	6 months 12 months	60 days 90 days

First name:

Last name:

Address:

City:

State/Prov:

Zip/Postal code:

Country:

Phone number:

Fax number:

Email address:

Category:                       (or we will assign the closest one)

SELECT THE DURATION OF YOUR LISTING (promotional prices):

CLASSIFIED AD

Per month basis - $10/month
Three-month listing - $20
Six-month listing - $30
Twelve-month listing - $50
Multiple Ads
Incremental 10% discount for each additional Ad (up to 50%)

MIRROR HOME PAGE

Six-month listing - $60
Twelve-month listing - $100
Multiple Ads
Incremental 10% discount for each additional Ad (up to 50%)

CREDIT CARD INFORMATION - This Form is secure. However, if you are still concerned about sending info via the Internet, send name, credit card number & expiration date by fax at (909)695-5235.

Credit card number (Visa/MC/Amex/Discover):

Expiration date:

TEXT for your Ad (maximum 300 words) or URL of the page to be mirrored:

Comments/Suggestions:

THANK YOU! Your Ad should be online within 48 hours.

If your browser does not support JavaScript, you might not see any changes after clicking on "Submit". If you do not receive an error message, your order was successfully sent to us.

IF ORDERING BY MAIL OR FAX
Please print & forward this page with your Cashier's Check, Money Order or credit card information payable to:
MyMall Network, 40222 Benwood Ct, Temecula, CA, USA 92591
FOR EXPEDITE SERVICE, FAX TO: 819.682.7630