Subscription Form
Specialists Group For Arab American Cash Patients
And Their Visiting Relatives
 

 How to use this Form:
n Use one Form per order
n Type in the Form, on screen response, (complete applicable blanks). 
n
 Press "TAB" to move between blank spaces. 
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.

.I would like to subscribe to the "Specialists Group For Arab Americans " according to marked boxes:
 

Special (50% discounted) Fees
Deadline: July 31, 2009

Regular Fees

New Member: $495/Year

New Member: $990/Year

Repeat Member: $245/Year X No. Years = $

Repeat Member: $490/Year X No. Years   = $

Multi-Specialty Listing: $195/Specialty/Year.  List sub-specialties:

Multi-Specialty Listing: $390/Specialty/Year. List sub-specialties:

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1

2

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.With my subscription, I would like to receive the following free services:

  1. A dynamic Arabic English languages web site : Sample
  2. Listing at the  following Arab directories:
PAYMENT: 
TOTAL AMOUNT SENT: $
Date payment was sent/mailed    Your check Number 

Name And Contact Information:
First Name
Middle Name
..		 Last Name
  		   Title (optional)
..
Clinic Name
Number  Street  Suite #
City
State/ Zip Code
Area Code
Telephone Number
FAX Number 
E-mail Address
Web Site Address 
Sending Your  Order Form

Please complete the Order Form, print it and mail it with your check written payable to:

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

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