55 Park Street East Suite 1102, Port Credit ON L5G 1L9

Phone: 647-865-8197 1-855-TALK-ASA (825-5272)
Fax: 1-888-594-6040
http://TheSeniorAgent.com
AccreditedSeniorAgent@gmail.com

Associate Member Advertising Order & Payment Form
Name: _______________________________________________________________________________
Company: ____________________________________________________________________________
Mailing Address: _______________________________________________________________________
Phone: ______________________ Fax: ______________________ Toll-Free: ______________________
Web Site: ______________________________________

Email: _______________________________

Category: ___________________________________ (e.g. Lawyer)
Sub-Category: __________________________________________ (e.g. Estate Lawyer)
Geographic Areas Served: _______________________________________________________________
Describe your company’s services (325 Characters or less, including spacing):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Advertising Program Chosen (as per information at http://ASAMembers.com/Star):
All-In-One Package

$100 per month, 12 month minimum

Member Site Only

$50 per month, 12 month minimum

$500 per year, Pre-paid

Public Site Only

$50 per month, 12 month minimum

$500 per year, Pre-paid

In-Class Promo Only $50 per month, 12 month minimum

$500 per year, Pre-paid

Set-Up Fee for All-in-One Package $100

$1,000 per year, Pre-paid

Set-Up Fee For Other Packages

$50

NOTE: All fees above are subject to 13% HST. Associate Member agrees to provide their own
artwork in the form of a JPEG. PDF files can be accepted, however, quality may not be as good.

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55 Park Street East Suite 1102, Port Credit ON L5G 1L9
Phone: 647-865-8197 1-855-TALK-ASA (825-5272)
Fax: 1-888-594-6040
http://TheSeniorAgent.com
AccreditedSeniorAgent@gmail.com

Associate Member Advertising Order & Payment Form Page 2
Note: All online ads should be non-animated, and sizable to 2” x 2”. For In-Class promo, ad should be
PDF format, size of regular business card.
Total Advertising Cost, per Selection: $ _________ + Setup Fee $ _________ = $ ______________ +
HST $ _______________ = Total Due: $ ________________
If paying monthly, by signing this form below, you hereby authorize us to charge your credit card in full
each month. NOTE: Monthly payments are only available via credit card.
Visa: ________ MasterCard: ________ Cheque: _______
Cardholder’s Name: ____________________________________________________________________
Card Number: _________________________________ Expiry Date: __________ / ____________
Cardholder’s Signature: _________________________________________________________________
Please Print Clearly and fax back to 1-855-825-1559
If paying by cheque, make cheque payable to:
The Accredited Senior Agent
Mail To: 55 Park Street East, Suite 1102
Port Credit Ontario L5G 1L9

For more information, please call 647-865-8197 or Toll-Free 1-855-TALK-ASA (825-5272)

I CERTIFY THE ABOVE INFORMATION IS CORRECT AND CONSENT TO MY CREDIT CARD BEING
CHARGED AS ABOVE, IF PAYING BY CREDIT CARD.
Authorized Signature: _______________________________________ Date: ______________________

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