Order Form- Basic Listing
Please print off this form, fill
in the information below and send along with cheque for $ 25.00 made out to
Eryn Wiedner and mail to
us at PO Box 75225, White Rock, BC, Canada V4B 5L4. If you have questions
please call us at (604) 614-7990.
** Pricing Information click here
** Please note: for the Premium Listing option ($40
per year) please click
here
REQUIRED PROVIDER INFORMATION
FACILITY NAME _____________________________________________________________________________________
CONTACT PERSON
_________________________________________________________________________________
OWNER/ MANAGER NAME
___________________________________________________________________________
LOCATION (CIVIC ADDRESS)
_________________________________________________________________________
MAILING ADDRESS
_________________________________________________________________________________
PHONE (
) __________________________
FAX (
) ______________________________
EMAIL
_____________________________________
AGES OF CHILDREN ______________________________
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