Reservation Form

REMINDER: Take a 4% discount for payment within 20 days of reservation

PRINT OUT AND READ THE AGREEMENTS .
PRINT OUT AND FILL IN THIS RESERVATION FORM THEN FAX OR MAIL IT TO WSC.

YES, we want to participate in the Wall-Street.com ®Microcap Leaders Program™.
Please include us in the approx. six-month Program presenting our story to Wall Street's specialzed microcap decision makers. We understand the $2,900 Program fee covers the entire four-month Program, including a print ad in BARRON’S, plus a four-month featured position at the MicrocapLeaders.com Website (including a prominent link from the Wall-Street.com Website). We will also receive the many additional services as detailed in the Agreements

I HAVE READ THE AGREEMENTS AND LIMITED GUARANTEE OF RESPONSE AND ACCEPT THEM AS WRITTEN.

Payment is enclosed: (or) Invoice us
Participants will receive a 4% discount from the $2,900 Program Fee ($2,784 NET) for payments received within 20 days of invoice date.

1. Company name: (Maximum 45 letters & spaces allowed for the company name. Leave off "Inc." or "Corp." or otherwise abbreviate if needed.)
   
   Our Company name is:                                                                                        
   
   
2. Web Address: Our Web address is: www.                                                                                        

3. Primary business activity in ads: (Maximum 45 letters & spaces allowed.)
   
                                                                                          

4. Our most recent year ends(ed) (date):                                    .
   
   
5. The annual report we send to respondents will be available on (date):                                    .
   
   
6. Please list some of the unique aspects of your company and/or recent corporate events that might be of particular interest to prospective investors. This is for WSC internal use only to determine your eligibility to be classified as a Microcap Leader and to be included in the Program:
   
   
   
   
   
   
   
   

7. Mailing Address:
   Company:                                                                                      
   
   Street address:                                                                                      
   
   City/State/Zip:                                                                                      
   
   
8. Ad responses go to:
   Name                                                                                      
   
   Title                                                                                      
   
   
9. Invoices go to attn. of:
   Name                                                                                      
   
   Title                                                                                      
   
   
10. Authorized by:
    Name:                                                                                      
    
    Title                                                                                      
    
    
11. Authorized signature:                                                                                      
    
    
12. E-mail:                                                                                                           
    
    
13. Main Phone #:                                              
    
    
14. Fax #:                                              
    
    
15. DD or Ext. #: