| *Full Name: |
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| *E-mail address: |
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Important! The e-mail address you provide may not be a free temporary web based e-mail address like hotmail
or yahoo! mail. You must use your ISP's e-mail address, like smith@aol.com or smith@msn.net or
smith@yourispname.com or a company e-mail address like, smith@mycompany.com. |
| *Telephone Number: |
Area Code( )
Prefix
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| *When is it best to call you? |
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| *City of residence: |
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| *State of residence: |
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| *Threapist Member Package Offering |
Basic Membership (Practioner Page): $150/year. Terms of Membership
Basic Membership with Home Page Hosting: $265/year including domain name registration.
Basic Membership, Hosting and Home Page design & development: $256/year + $50/hour for development. |
| *Hosting Your Home Page |
Yes, and I agree to The Terms Of Service, set up my hosting site now.
No, I will decide about this later. |
| *Home Page Domain Name: |
Note: A domain name is required for your Home Page Hosting site setup.
Please include: .com/.net/.org/.cc/.us/.info/.biz/.au, etc.
Check the availability of a domain |
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I have a domain name already and have entered it on the line above.
Please set one up the one listed above for me for $15.00/year.
I will decide about this later.
I don't have one, but will get one myself and send it to you(a pre-req for hosting site setup).
Help, please set up my Psychotherapy-Membership, but call me to explain Home Page Hosting and Domain Name. |
| *How did you hear of us? |
Internet
Mail Offer
E-Mail Offer
friend
associate
newspaper
Yellow Pages
Other |
| Your Comments |
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