Company

Contact person

Full address

Telephone (with country & area codes)

Fax (with country & area codes)

E-mail

Option chosen (Banner or Panel?)

For how many months?

From which date to which date?

Will you supply the banner or panel? Yes/No

Do you have a home page to which your ad should be linked? Yes/No

If answer to above is 'yes', what is its URL?

If you don't have a home page, do you one free? Yes / No

Will you pay in Indian rupees or US dollars?

Total amount payable

Special instructions or query (if any)

Date (day/month/year)