VIP + Listing Form Page

Please provide the following information:

Business/Organization

Street address

Address (cont.)

City

County

State if other, specify in comments below

Zip/Postal code

Phone

FAX

E-mail

URL(web site)

Do you want your E-mail address listed?    YES NO

Do you want your URL listed?    YES NO

Please provide your contact information, for questions:

First name

Last name

Phone

Email

Do you want this contacts name listed?    YES NO

Suggest one general category which best fits your business/organization.

Where did you find us?

Please suggest the specific keywords which best describes your business/organization.

Up to 100 word description of your business/organization/company

If your billing information is different from information listed above,
Please enter that information below:

Same as above (check if applies)

First name

Last name

Middle initial

Title

Phone

Organization

Street address

Address (cont.)

City

County

State if other than MI, please give in comments.

Zip/Postal code

E-mail

1 Year Commitment required: I agree I disagree
(by disagreeing to a 1 year commitment, it our right to decide not to run your listing)

I Agree to receive emails / mailings from
GreatLakesonLine.com & LR Associates, Inc.

Comments

Enter Security Code:

Green = required information

(your information is kept completely confidential)

Please complete form as completely as possible,
then click the Submit Information button ONLY once.

You will be contact you within 3 weeks for your
credit card information. Thank you.

**If you have any questions regarding a listing**
Please call: Laurie at 248.486/6033