STEP 1 of 4:
Please Enter Your Contact Information...

YOUR NAME:  


COMPANY NAME (Leave Blank if not Applicable):  

 
EMAIL ADDRESS:  


PHONE:

STREET ADDRESS OR PO BOX:  
 
CITY: 

STATE:  

ZIP CODE:  
 
COUNTRY:  

STEP 2 of 4:
Enter the URL Web Address location of your Banner:

 (.gif or .jpg files only)
Example:  http://www.mywebsite.com/images/mybanner.gif

Enter the URL Web Address of your Link's Landing Page
          (Your Home Page Web Address)

Example:  http://www.mywebsite.com

Enter the Text you want to appear when a mouse is rolled over your Banner
          (Normally a phrase describing your website, or it could be just your domain name)
 40 Characters Maximum
Example:  'The John Doe Website' or 'JohnDoeMusic.com'

Total Amount Your Credit Card will be Charged:

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:  Visa M/C American Express Discover                                            
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:  
 
ZIP CODE:  

Please Double Check Your Credit Card Number
( If You Enter an Incorrect Number Your Order Cannot be Processed )

STEP 4 of 4
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 and Conditions.

    .

Please Allow The Order Submission To Fully Complete…
(This May Take Up to 2 Minutes)
When Completed A Page Will Appear Telling You
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 be Posted
Usually Within 24 to 48 Hours!

Please Print Out a Copy of this Order Form to Keep as a Receipt.

Contact La Costa Music

The Music Business One-Stop™

Classic Retro Website