Avision Media - Your success begins with A Vision.

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Your success begins with A Vision.

Banner Ads Design Order Form

TO ORDER: Complete the form below. Once you have submitted your order form, you will be able to make your payment on the next page. If you would like to send your order by regular postal mail, please print out this order form and return with copies of your current ads and your payment payable to:

        Avision Media
        P.O. Box 6476
        Albany, NY 12206
        (518)986-2448

If you have any questions or would like to receive further information please [ Click Here ] Allow 1 to 5 days for most ads to be completed. (Some ads may require more time.)

All information submitted in this form will be kept confidential and will not be given or resold to any other parties.

Services: Banner Ad Design -

Amount Enclosed:

Name

Business Name

Address*(street address is require)*

City, State & Zip

Country(if not in USA)

E-mail address

Payment Method: (complete this portion only if you are sending your payment by regular postal mail)
[]Check []Money-Order []Credit Card

Credit Cardholder Name:______________________________________________
Credit Card#: _______________________________________________________
Exp. Date: ________________________
Signature: ________________________________________________

Title of website

Website address of a copy of your ad:

Choose a category for your business or website.

If other please specify

Write you current ads or the text you would like to appear in your ads below.

Please write a description of your business, products, services or website below:

How Did you find this site?
Please write any additional questions, comments copy of your current ads below:

Would you like your questions or comments posted?Yes No

Avision Media
"Your Success Begins With A Vision"
P.O. Box 6476
Albany, NY 12206
(518)986-2448
webmaster@avisionmedia.4t.com

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