#### Enrollment Form
|  | (Less than 50 Character Ads) Contact Information:
|  | Name |
|  | Company |
|  | Address |
|  | City/State/Zip |
|  | Phone |
|  | Web Site |
|  | E-mail |
|  | Advertisement Headline, Description & URL Information:
|  | Headline (up to 25 Characters)
|  | Description (up to 50 Characters)
|  | Display URL (maximum 35 characters)
|  | Destination URL (maximum of 1024 characters)
|  | Advertisement Duration, Agreement and Payment:
Start Date mm/dd/yy | End Date mm/dd/yy
Number of months | X Monthly fee of $100.00 = Total
|  | ISCEA Standard Terms and Conditions:
|  | I Agree
|  | Mail a check Pay Online (Visa, Master Card, Discover, Amex)