BAITNET.COM GLOBAL AD BOX ORDER FORM

Please choose from one of the following three options for your ad box on our web site. Please circle only one option: 1) 100,000 global views - $60 2) 200,000 global views - $100 3) 500,000 global views - $200 we will notify you when your ad gets down to 5,000 views left If you want BaitNet.com to make an image for your ad box, put an “X” in this box If you would like to send us your own image, 90 pixels tall by 130 pixels wide, and less than 15kb, put an “X” in this box According to the option you have selected above, please send a check or money order in the proper amount, US funds only, to:

Andy Bartels BaitNet.com

P.O. Box 324 La Crosse, WI 54602-0324

Also, please fill out the form below to receive your free enhanced database listing.

** Please fill out the form below completely and accurately! ** We will send you an itemized receipt by mail that lists your service period dates. ********** Owner/Manager Name (your name will not appear on the website): _________________________________ Business name: __________________________________________________________________________ Address: _______________________________________________________________________________ City: ________________________________________ State: ___________ Zip: ____________ County: __________________________ Toll free number: (_____)_______________________ Telephone (include area code): (_____)__________________________ Fax number: (_____)_________________________ E-mail address: _____________________________________________________________________________________________ Internet address: ____________________________________________________________________________________________ Regular hours: ______________ Dates: ______________________________________________________________________ Special hours1: ______________ Dates: ______________________________________________________________________ Do you sell licenses (Y/N)? ____ Do you sell convenience items (Y/N)? _____ Miles to gas nearest station? _____ Nearby waters - names: ________________________________________________________________________________________ ___________________________________________________________________________________________________________ Primary fish species nearby: ____________________________________________________________________________________ Sell live bait (Y/N)? ____ Bait selection:__________________________________________________________________________ ___________________________________________________________________________________________________________ Sell tackle (Y/N)? ____ Tackle selection: _______________________________________________________________________ ___________________________________________________________________________________________________________