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Annual Subscription Fee $199				Prices do not include $199 subscription fee.				Card #:_____________________________
(a link to your web presence)				Webpage	Loc Sponsr	Rgnl Sponsr	Natl Sponsr	Expires:_________  Security Code_______
Please include your check with application				$199	To $499	To $1,499	To $5000	Name on Card:
Your Entity Name & Address				Your Name				Your Current URL
Name:
Address:				Your Title				Your Email Address
				Your Phone #				Special Requests
County:
Number of Employees:				Your Fax#
Annual Sales:
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Growing	New	Small	Medium	Large	Home Based	Subsidiary	Franchise	Corporate	Partnership	Sole Proprtr	Other
Tell us your business story (the Founder, special features, why should people patronize your business, how you got started, etc.)
Please circle below all categories that best describe your primary customers:
One Time	Repeat	Seasonal	Occasional	Online	Walk In	Individuals	Businesses	Corporations	Resellers	Consumers	Government
Men	Women	Ethnic	Educational	Home Owner	Wealthy	Young	Mature	Industrial	Healthcare	Professionals	Other
Is your company a volunteer organization?					Are you interested in trading or bartering your services?
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Are you politically motivated?					Does your company have similar offices in multiple cities?
Today's Date				Your Signature				Office Use
Mail to: Local Computerized Services, P.O. Box 6708, Falls Church, VA  22046 Attn: KG Lee
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