OC Beauty & Health - Subscription Form

OC Beauty & Health
Consultant Subscription & Advertisement Form

How to use this Form:

n Use one Form per consultant

n Type in the Form, on screen response, (complete applicable blanks).

n Press "TAB" to move between blank spaces.

n Fields marked with * are required fields.

n DO NOT CLICK ON "ENTER" while completing the form. If you do that, you will close the form and send incomplete Form!

n DO NOT press the "BACK" button because all information will be deleted if you leave this web page.

Name:


First Name *	Middle Name	Last Name *	Specialty *

Degree(s):. Business Name:

	Please register my name as a consultant for OC Beauty & Health.
	Registration Agreement: * I agree to inform in writing (US mail or E. Mail) my patients or my clients about the web site address http://www.ocbeautyhealth.dmsindex.com for "OC Beauty & Health" and invite them to view it. Signature. Date

Registration Fees:
Registration Fee Per Month: $40, Minimum Registration Period: 3 Months ($120)
I would like to register as a consultant at OC Beauty & Health (please select a period):

	3 Months - $120		6 Months - $240		9 Months - $360		12 Months - $480
	15 Months - $600		18 Months - $720		21 Months - $840		24 Months - $960

Advertisement Rates:
Right and left panels of the web site are assigned for advertisement.
Minimum Advertisement Space: 1 X 1 Inches. Rate: $25/Month
Larger advertisement ads are available under a caption linked to the main advertisement.

Your Order: 1 Insertion/Month

	For 1 Month - $25		For 3 Months - $75		For 6 Months - $150		For 9 Months - $225
	For 12 Months - $300		For 15 Months - $375		For 18 Months - $450		For 21 Months - $525

Other advertisement period, please contact DMS (949) 583-7599 so that to quote you a fee:

Contact Information: (Please complete only applicable information)

Address (Street No, Suite #) *
City *
State/ Zip Code *
Area Code *	Telephone Number FAX Number
E-mail Address
Web Site Address (if available)

Please complete, then print the Registration Form and mail it with your check made payable to:

Doctors' Marketing Service
P.O. Box 748
Lake Forest, California 92609-0748

n		Use one Form per consultant
n		Type in the Form, on screen response, (complete applicable blanks).
n		Press "TAB" to move between blank spaces.
n		*Fields marked with are required fields.**
n		DO NOT CLICK ON "ENTER" while completing the form. If you do that, you will close the form and send incomplete Form!
n		DO NOT press the "BACK" button because all information will be deleted if you leave this web page.