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ANNUAL BILLING INFORMATION This WILL NOT appear online. | |||||
Send our receipt and placement confirmation to this e-Mail address: ___________________________________________________________________________________________________________ (This address will NOT be given, sold or leased to 3rd Parties) Billing Street or P.O. Box: ___________________________________________________________________________________ City: ______________________________________________________________ State/Prov: ____________ Zip: _____________
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PREMIUM LISTING INFORMATION This WILL appear online. | |||||
Main
Office Listing: Company Name: ____________________________________________________________________________________________ Main Office Address: ________________________________________________________________________________________ City: ______________________________________________________________ State/Prov: ____________ Zip: _____________ Phone (Area code): ______________________________________ Fax (Area code): ____________________________________ Web Address: http:// ________________________________________________________________________________ or N/A Reply to e-Mail Address: ____________________________________________________________________________________ Premium Listings for Additional Offices: (Enter the address, city, state, zip, phone & fax numbers for each. Attach a separate sheet if needed) 1) Address: _______________________________________________________________________________________________ City: _____________________________________________________________ State/Prov: ____________ Zip: _____________ Phone (Area code): _____________________________________ Fax (Area code): ____________________________________ 2) Address: _______________________________________________________________________________________________ City: _____________________________________________________________ State/Prov: ____________ Zip: _____________ Phone (Area code): _____________________________________ Fax (Area code): ____________________________________ 3) Address: _______________________________________________________________________________________________ City: _____________________________________________________________ State/Prov: ____________ Zip: _____________ Phone (Area code): _____________________________________ Fax (Area code): ____________________________________ 4) Address: _______________________________________________________________________________________________ City: _____________________________________________________________ State/Prov: ____________ Zip: _____________ Phone (Area code): _____________________________________ Fax (Area code): ____________________________________ |
PAYMENT
OPTIONS The annual fee is non-refundable after your order
has been placed on ActiveSET.org.
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OPTION
1 - Pay By Check
Mail the completed form with a U.S. Check or Money Order in U.S. Funds for the $300 annual fee payable to: ActiveSET.org 3335 NW 47th Terrace Gainesville, Florida 32606 |
OPTION
2 - Pay By Credit Card
I authorize Emissions Schematics to bill my
credit card $300 (USD) for the annual fee. ActiveSET.org is owned
and Cardholder's
First and Last Name as it appears on the front of the card: |