1 of 4:
Please Enter Your Contact Information...
COMPANY NAME (Leave Blank if not Applicable):
STEP 2 of 4:
Enter the URL Web Address location of your Banner:
STEP 3 of
Enter Your Credit
Use Valid Credit Cards Only!
(Do Not use ATM Debit Only Cards, Check Cards, etc.)
All FIELDS BELOW ARE REQUIRED TO PROCESS ORDER:
CREDIT CARD You Wish To Use For Payment:
Name On Card: (Type-in Your Name exactly as it appears on card)
Card Number: (Type-in Number with NO spaces between numbers)
Credit Card Verification Value: (3 Digit # Located After the Card # on the Back of Your Card…Amex is a 4 digit # on Front of Card)
Expiration Date: (mmyy) Example: 0408 would be April, 2008
Address of Credit Card Holder
… MUST INCLUDE TO VALIDATE CARD
( i.e., Address where You Receive Your Credit Card Billing Statement )
STREET ADDRESS OR PO BOX:
Please Double Check Your Credit Card Number
( If You Enter an Incorrect Number Your Order Cannot be Processed )
STEP 4 of
Click on the
"I AGREE...SUBMIT ORDER" button to place your order…
By clicking on the
button, you are acknowledging that you are 18 years or older,
and have fully
read, understand, and agree to the Terms
Please Allow The Order Submission To Fully
(This May Take Up to 2 Minutes)
When Completed A Page Will Appear Telling
That Your Order Has Been Successfully Received.
If For Some Reason Your Submission Times Out, or You
Have Other Difficulties,
Then Re-submit the Order…Your Credit Card Will Not Be Charged Twice.
Your Image and Link will
Usually Within 24 to 48 Hours!
Please Print Out a Copy of this Order
Form to Keep as a Receipt.
La Costa Music All Rights Reserved