State Page Store Advertisement Insertion Form

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Name ____________________________________  Title _________________
Store Name _______________________________________________________
Address __________________________________________________________
City _________________________  State ______________  Zip ________
Phone ________________  Fax _____________  Email _________________
Your URL (web site address):______________________________________
Page(s) you'd like to be listed on:_______________________________
15 words or less describing your store: __________________________
__________________________________________________________________
(_) 3 months, $50
(_) 3 months, $100
(_) 6 months, $75
(_) 6 months, $150
(_) 1 year, $99
(_) 1 year, $199
(_) 2 years, $150
(_) 2 years, $300
 
MC/VISA/AmEx/Discover # ____-____-____-____  Exp. Date _____/_____
I have read and agree to Homeschool World's terms and conditions.
Signature ________________________________________Date _____/_____

Questions? Call us at (636) 343-6786 or fax (636) 225-0743.

Return with payment to:
Home Life, Inc., 1731 Smizer Mill Rd., Fenton MO 63026-2635. Fax: (636) 225-0743

Subsequent payments will be billed or charged at current rates as the old payment expires.
Cancel anytime and receive a pro-rated refund, less $50 set-up fee.