Pico Community.com
Local Business Community Directory

Order Information Form

Please provide the following billing information. Certain fields are required to submit this form. You will be contacted within 3-5 days regarding your order.

Billing  Information
First Name Required
Last Name Required
Title Required
Company Required
Street Address Required
Address (cont.)
City Required
State Required
Zip Code Required
Work Phone Required
Cell Phone Optional
FAX Optional
E-mail Required

Basic Listing $150 per year

Select the appropriate category for your listing. 
Category 1
Category 2 Add $50

Choose at least five lines for your basic listing
Line 1
Example: Company Name
Line 2
Example: Company Motto
Line 3
Example Address, City, State, Zip Code
Line 4
Example: Phone, Fax, Hours Open
Line 5
Example: Location Map
Location Map   Yes No
Line 6 Add $25

Do you have more than one location? Yes No 

Do you have a website?  Yes No 
If yes what is it? www.
Would you be interested in a web add?  Yes No 
How would you like to be contacted?
E-mail
Phone
By Appointment

Addtional Comments


Copyright © 2005 KwaZar MultiMedia  All rights reserved. Updated: April 15, 2005