Your Full Name:
Your Company:
Address:
City, State Zip:
E-Mail:  REQUIRED
Day Phone:
Evening Phone:
FAX:

How would you categorize yourself?	(select one) Individual merchant An ISP A Web Developer/Consultant Webmaster Mall Operator Other Agency
What do you want to sell online?	(select one) Books/Publications Music-related Clothing Food/Spices/Sauces Adult Products Professional Services Other Services MLM/Network Marketing Gifts & Novelties Housewares Flowers Crafts & Supplies Business Products Electronics
If not listed, please describe:
How many products do you sell?
Where did you hear about us?	(select one) E-Mail Newsgroup Friend/associate ISP/Consultant Web Search An online reference Other
What's the best way to contact you?	(select one) E-Mail Telephone
What services are you interested in? check all that apply For info see the Options page.	Basic VOE Package Extended VOE Package Database VOE Package Other Options: Custom headers & footers PGP E-Mail encryption Secure Web Order Pickup Order FAXing Local Hosting Virtual Domain Other CGI/Script Services... Ad Rotation Guest Books Counters E-Mail Accounts Mailing List E-Mail Auto-Responder Other:

For what website (if already online) are you interested in using the VOE?

Please specify the URL:  

How are you handling shipping charges? (select one) charge per item based on total purchase amount based on weight based on method varies no shipping charges

If you are calculating shipping based on total weight or amount of order, please provide the 'look-up table' below. Here's an example:

Amount of Order:	Shipping:
² 20.00	5.00
² 40.00	8.00
² 100.00	10.00
² 200.00	15.00
³ 9999.00	25.00

What E-Mail address are orders to go to:

What Credit Cards do you accept? (check all that apply)

MasterCard/VISA	American Express
Discover	Diner's Club
Others:

Enter any other comments on your application, or any features or inquiries regarding our service you may have: