Retirement Snapshot Advertising

Application Form

STEP #1: Make Your Advertising Choice

• __  500 Count: “We do it all for you postcards” can be sent on the 15th of every month

               for the low price of just:  $360.66

• __ 1000 Count: “We do it all for you postcards” can be sent on the 15th of every month

              for the low price of just:  $699.00

• __ Display and Classified Ads   Price $______________  Ad #____________ 

              Paper Name__________________________________     __ Display   __ Classified

• __ Email Blaster   Price $ ______________     Ad #____________ 

              Publication ___________________________________

              Website Address _________________________________________________

STEP #2: Fill Out Payment Instructions.

__Check

__ Credit Card  ____ Visa  ___ MasterCard   ___ Discover  ___ American Express

Credit Card Number_________________________________________ Expires_________

3 or 4-Digit Security Code__________

Signature:___________________________________________

STEP #3: Include Your Contact Information.

Your Name_______________________________________________________________

Business Name____________________________________________________________

Address__________________________________________________________________

City/State/Zip Code_________________________________________________________

E-mail Address____________________________________________________________

Daytime Phone Number_____________________________________________________

STEP #4: Rush Your Acceptance Form to Us Fast.

Mail To:   GoldMine Web Design, LLC             Fax: 316-838-5353                Call Toll Free 877-207-9900

                 2020 W. 21st St. #96

                 Wichita, KS 67203