Please provide the following information:

Name
Title
Organization
Postal Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
URL

Please provide the following ordering information:

QTY	DESCRIPTION
1 year	Diving Section Advertising  @  US$75.00
.

CATEGORY/SECTION OF YOUR CHOICE
YOUR KEYWORD CHOICE
1.	2.	3.
.
BANNER	Sea-Ex designed	I will supply
Please give a description of your products and services and any relevant information you would like included in your advertisement:

	BILLING
Credit Card	Please choose one of the following: VISA MasterCard Bank Draft/check TT - We will contact you with details
Cardholder Name
Card Number
Expiration Date

*Australian companies please note that this is +GST