APTA Alabama Advertising

Complete this form to purchase advertising online using a credit card. If you would prefer to pay by check, click the button below to download a printable copy of the advertising order form.

APTA Alabama Advertising Order Form

Name*
First Last
Company or Organization Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Enter Email Confirm Email
BANNER AD Quantity
Price: $100.00
Advertisement placed on our website with a link to your URL. Please enter the number of months you would like your ad to run in the quantity field.
EVENT CALENDAR
MAILING LIST PURCHASE
BLAST EMAIL
Total
$0.00
Credit Card*
Card Details
Cardholder Name
To complete your submission, you must make the following certification by checking the “I agree” box below:*
I AGREE
“I certify that no referral source (including any referring physician) has a financial interest in the practice that has the position that is the subject of this advertisement.”
Signature*
Date*
MM slash DD slash YYYY
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Email
This field is for validation purposes and should be left unchanged.

APTA Alabama Advertising

APTA Alabama Advertising Order Form

“I certify that no referral source (including any referring physician) has a financial interest in the practice that has the position that is the subject of this advertisement.”