Floral Image - Dallas Credit Card Form

Journal Ad Payment Form

Please complete this form in order to make payment via credit card

My Products

PREMIUM PAGE (8.5”W X 11”H)

$1,000.00 Quantity

FULL PAGE (8.5”W X 11”H) $750

$750.00 Quantity

HALF PAGE (8.5”W X 5.5”H)

$550.00 Quantity

QUARTER PAGE (4.25”W X 5.5”H)

$250.00 Quantity

Total

$0.00

Organization
Company Name
E-mail
example@example.com
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By signing below I hereby authorize the company to charge my credit card for the amount shown above on a month to month basis.
Authorization Signature

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Journal Ad Payment Form