Your personal name: Trading as name: Address: Town: City: Post Code: Telephone: Public E-mail (the one every one can contact you with): Services provided, you can add more later: A short message about your services, to get your page going: Paying by card, enter type, Visa, Master, etc: Issue Number SWITCH ONLY: Card Number: Card Security Code, last three digits in signature strip: Starts: (mm/yy) and Expires: Amount to be debited One year basic 15 - Three year basic 30 One year single image 20 - Three year single image 40 One year multi image 25 - Three year multi image 50 Price includes maintenance and updating as you require. We will debit your card once the basic site has been uploaded. This is for the one or three years. We will email you when renewal is due. Take a print out of this page for your own records. Email this form to You can pay by card over the phone 01792 229191 Tuesdays to Fridays 9.30am till 1.00pm Or post with your cheque payable to Galaxy Studios The Weddings in Wales Website Galaxy Studios 78 High Street Gorseinon Swansea SA4 4BL