Purchase a Web Banner Ad

Fields with a * are required. You must include data in those fields or AAPS Online will be unable to process this form. If you have questions about this please contact the webmaster .

1. * Contact Information:

Contact First Name:
Contact Last Name:
Company Name:
Address:
Address (Cont'd):
City:
State:
Zip:
Country:
Phone:
Fax:
E-Mail:

2. * During which month(s) would you like your ad to be displayed?

3. * Use the 'Browse' button to locate your banner ad file on your computer.
Please enter the full URL where you wish the banner ad to link to.

Attach your image file here: Please be sure to only upload images.
Banner URL: The full internet address including https:// where banner should link:

4. Secure Online Credit Card Payments

You can make your credit card payment online. AAPS Online is set up to take secure transactions. You will be charged $800/month for your ad. Charges will be billed in total. We accept Visa, MasterCard, American Express and Discover. If you prefer to pay by check please print this form, fill it out, and send it to us with the check and a disk with your image.

Credit Card Type:
Credit Card Number:
Expiration Month
Expiration Year
Cardholder Name:

5. Authorize Payment

I authorize AAPS to charge me $ for the placement of this online banner advertisement.

All credit card information is sent via encryption. Any questions should be submitted to Chris Reed . Submission of this form without accepting payment authorization is subject to review, confirmation and invoicing. It is in the interest of both parties to authorize payment and expedite this process.