Application

Make check payable to:	* Invoice #: _________________
Make check payable to:	* (Invoice # to be assigned by MCA)
Modern Communication Assistance (MCA)	Date: _______________________
PO Box 184	For directory listing in:
Macon, Mo 63552	http://www.maconinformation.com
Customer Information:
Name: _________________________________________	Phone: ______________________
Address:________________________________________	Phone: ______________________
City: __________State: _____Zip: ___________________	Fax: ________________________
Contact Name: ___________________________________	Email:_______________________
Contact Name: ___________________________________	http://www.___________________

Pricing:			Method of Payment:
Number of Listings:_____	@ $ 40.00 =	Sub Total: $_______	*Cash: $ __________
Number of Listings:_____	@ $ 20.00 =	Sub Total: $_______	Check: # __________
*If you list in 3 categories, the 3rd one is 1/2 price.			*Do not mail cash
		Total : $______

Sales Representative: ________________________________________	Date: _________

Thank you, we appreciate listing your business in the directory.

For assistance with listing your business, see the "Contact Information" page. Thank you.