Monthly Click-Thrus -
Secure Order Form at the BannerCo-Op

Yes! I want to put my web site on autopilot. Count me in! I understand I may write to you via email or snail mail and cancel any time.

(When you sign up, we'll set up a stat page for you at BannerCo-Op.com specifically for this program & send you your passcode and viewing instructions.)

 
Name
Company Name
Address
City
State
Zip/Postal Code
Country
Phone (Day)
Phone (Eve)
Fax Number
Pager Number
Email Address
Your Banner URL*
Example: http://www.yourdomain.com/yourbanner.gif
Your Web Site URL
We need this so we can link your banner properly!

*If you don't have a banner yet, just go to our Design Help page, where you can build one free online, or hire the pros for just a few $.
 
How Many Click-Thru Visitors Do You Want Each Month?

 

For only $30 monthly, I'll get 100 visitors (that's only 30 cents each)

For only $35 monthly, I'll get 125 visitors (that's only 28 cents each)

For only $40 monthly, I'll get 150 visitors (that's only 27 cents each)

For only $50 monthly, I'll get 200 visitors (that's only 25 cents each)

 

 
Payment Information - Credit Card Option

Please charge my credit card monthly as indicated by the participation option I have chosen above. I reserve the right to write you at any time and cancel this option, with 30 days notice. 

Please charge my: 
 

Visa

Mastercard

Discover

 

Card Number

Exp. Date

Name on Card

 
 
Payment Information - Checking Account Option

Please debit my checking account monthly as indicated by the participation option I have chosen above. I reserve the right to write you at any time and cancel this option, with 30 days notice. 

To use your checking account for payment, please follow these simple instructions: (U.S. residents only)  

  • Take a check from your checkbook, fill it in as if you were going to mail it to us, then record it in your check register. 
  • Make your check payable to: BannerCo-Op, Inc.
  • Copy ALL the information on that check to this form.  NOTE: The information you provided above (name, address, etc.) must match the information as it appears on your check exactly. 
  • Write "VOID" on your check and keep it as a receipt. 
  • Your payments will appear on your next and subsequent bank statements. 

 

Bank Transit Code

Please enter the following required account information from your check.  
 

Bank Transit Code

  (See example above; Bank Transit Code is the series of "fractional" numbers from the upper right hand corner of your check) 
Numbers from the bottom of your check: (see example above) 

Bank Number

Your Account Number

Check Number

Please enter ALL the numbers on the bottom of your check 
(from left to right)

Bank Information:  

Bank Name

City

State

Telephone #

   
By entering and submitting your checking account information, you make the following statement:  "I wish to place an order, and hereby authorize BannerCo-Op, Inc. to duplicate the enclosed check information in bank draft form. I understand that the Payee, (BannerCo-Op, Inc.) or authorized agent of Payee, will sign the bank draft as my agent for these transactions."
  
Comments or special instructions 
 
 
 
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