ESCORTS-CANADA.COM
                 Advertising Application Form - Agency

Return Form To:       

DeSign Co.
22 Commerce Park Dr.
Unit C - Suite 264
Barrie Ontario
L4N 8W8


Phone for More Information if Required
Phone (705) 792-2025
Toll Free 1-800-250-2611 (Message & Fax Only) 

EMAIL US


E-mail: info@escorts-canada.com 

             
Company Name: * __________________________________________________

Headline: *   ____________________________________________________

Service: *    __ Escort      __ Massage      __ Phone     __ Other

Staff are: *  __ Female    __ Male    __ Couples

City: *      _________________________  Province: * ______________

Area Code: * __________   Business Phone: * ______________________

E-mail:      ________________________  Show e-mail?:  __ Yes __ No

Web Site:    _____________________________________________________

Password: *  __________________________ (4 - 15 characters)

Question: *  _____________________________________________________
             ( a question that we can ask you to remind you what 
               your password is, in case you forget it. )

In / Out:    __ In-Calls    __ Out-Calls

Clients:     __ Male Clients  __ Female Clients  __ Couple Clients

Accept:      __ Visa       __ Mastercard       __ American Express

Ad Text: *   _____________________________________________________

             _____________________________________________________
             (  You can include as much text here as you like.   )
             (  Attach another page if more space is required.  )