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

"*" indicates required fields

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

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

Credit Card*

Card Details

Cardholder Name

“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*